The Alopecia Areata Severity and Morbidity Index (ASAMI) Study
Authors:   ASAMI Consensus Survey Study Group, Moussa Anthony , Bennett Michaela , Wall Dmitri , Meah Nekma , York Katherine , Bokhari Laita , Asfour Leila , Rees Huw , Abraham Leonardo Spagnol , Asz-Sigall Daniel , Basmanav Fitnat Buket , Bergfeld Wilma , Betz Regina C. , Bhoyrul Bevin , Blume-Peytavi Ulrike , Callender Valerie , Chitreddy Vijaya , Combalia Andrea , Cotsarelis George , Craiglow Brittany , Dhurat Rachita , Donovan Jeff , Doroshkevich Andrei , Eisman Samantha , Farrant Paul , Ferrando Juan , Gadzhigoroeva Aida , Green Jack , Grimalt Ramon , Harries Matthew , Hordinsky Maria , Irvine Alan , Jolliffe Victoria , Kaiumov Spartak , King Brett , Lee Joyce , Lee Won-Soo , Li Jane , Lortkipanidze Nino , McMichael Amy , Mesinkovska Natasha Atanaskova , Messenger Andrew , Mirmirani Paradi , Olsen Elise , Orlow Seth J. , Ovcharenko Yuliya , Piraccini Bianca Maria , Pirmez Rodrigo , Rakowska Adriana , Reygagne Pascal , Rudnicka Lidia , Corralo David Saceda , Senna Maryanne , Shapiro Jerry , Sharma Pooja , Siliuk Tatiana , Starace Michela , Suchonwanit Poonkiat , Takwale Anita , Tosti Antonella , Vañó-Galván Sergio , Visser Willem I. , Vogt Annika , Wade Martin , Yip Leona , Zhou Cheng , Sinclair Rodney 
Published: February 2024

ImportanceCurrent measures of alopecia areata (AA) severity, such as the Severity of Alopecia Tool score, do not adequately capture overall disease impact.ObjectiveTo explore factors associated with AA severity beyond scalp hair loss, and to support the development of the Alopecia Areata Severity and Morbidity Index (ASAMI).Evidence ReviewA total of 74 hair and scalp disorder specialists from multiple continents were invited to participate in an eDelphi project consisting of 3 survey rounds. The first 2 sessions took place via a text-based web application following the Delphi study design. The final round took place virtually among participants via video conferencing software on April 30, 2022.FindingsOf all invited experts, 64 completed the first survey round (global representation: Africa [4.7%], Asia [9.4%], Australia [14.1%], Europe [43.8%], North America [23.4%], and South America [4.7%]; health care setting: public [20.3%], private [28.1%], and both [51.6%]). A total of 58 specialists completed the second round, and 42 participated in the final video conference meeting. Overall, consensus was achieved in 96 of 107 questions. Several factors, independent of the Severity of Alopecia Tool score, were identified as potentially worsening AA severity outcomes. These factors included a disease duration of 12 months or more, 3 or more relapses, inadequate response to topical or systemic treatments, rapid disease progression, difficulty in cosmetically concealing hair loss, facial hair involvement (eyebrows, eyelashes, and/or beard), nail involvement, impaired quality of life, and a history of anxiety, depression, or suicidal ideation due to or exacerbated by AA. Consensus was reached that the Alopecia Areata Investigator Global Assessment scale adequately classified the severity of scalp hair loss.Conclusions and RelevanceThis eDelphi survey study, with consensus among global experts, identified various determinants of AA severity, encompassing not only scalp hair loss but also other outcomes. These findings are expected to facilitate the development of a multicomponent severity tool that endeavors to competently measure disease impact. The findings are also anticipated to aid in identifying candidates for current and emerging systemic treatments. Future research must incorporate the perspectives of patients and the public to assign weight to the domains recognized in this project as associated with AA severity.