New Wave of Tools Adds Precision to AA Assessment

The Severity of Alopecia Tool (SALT) has long been the predominant instrument used to assess hair loss in alopecia areata (AA), but a new review article shows more recent tools have helped paint a clearer picture of how the disease affects patients, including children.

Amy S. Paller, MS, MD, and Dingyuan Iris Sun, BA, both of the Northwestern University Feinberg School of Medicine, outlined the latest tools for assessing AA in pediatric patients in a new report in Pediatric Dermatology.¹

SALT has been around since the early 2000s, Paller and Sun noted. It asks clinicians to assess the scalp from 4 different viewpoints and then use weighted averages of hair coverage to calculate patients’ scores. An updated version, SALT II, refined the system by dividing the scalp into 1% increments, which the authors noted is roughly the size of a thumbprint.

“This method allows for quick and consistent assessments, especially in cases in which small patches of hair loss are predominant,” the authors noted.

Still, Paller and Sun said both SALT and SALT II were initially developed for adults, whose head shapes have significant differences from the head shapes of children. An adjusted version of SALT, called pSALT, was thus developed to more accurately assess AA in children.

Even as SALT has been refined, though, the investigators said it still has one major flaw: it only accounts for scalp hair loss, and thus ignores eyebrow and eyelash loss, nail involvement, and the psychological impacts of the disease.

The authors then turned to outlining some of the newer efforts to assess AA. These include the Alopecia Areata Investigator Global Assessment (AA-IGA), which classifies hair loss into 5 severity categories based on SALT score. Though it does not incorporate factors like psychosocial impacts, the assessment was developed with patient input, and that input included patients as young as 12.

Another tool, the Scalp Hair Assessment Patient-Reported Outcome (PRO), on the other hand, is driven entirely by patient perspectives. It asks patients to self-report the extent of their hair loss using a 5-category framework similar to that of AA-IGA. Paller and Sun said this tool is successful in its effort to enable personalized treatment strategies, since it strongly incorporates patient voices.

While most assessment tools focus on the scalp, the authors said there are also clinician-reported and patient-reported measures for eyebrow, eyelash, and nail assessment.

“These measures provide clinicians with standardized tools to assess the severity and progression of AA in these specific body areas, allowing for more detailed and targeted treatment approaches,” they said.

Two other approaches aim for a more holistic view of the disease. The Alopecia Areata Scale (AASc) uses 3 categories to quantify scalp hair loss, but it also incorporates criteria related to psychological functioning, noticeable involvement of eyebrows and eye lashes, response to treatment, and hair-pull test results.

Finally, the Alopecia Areata Severity and Morbidity Index (ASAMI) uses the AA-IGA hair-loss assessment but combines it with a number of other factors, including disease activity and quality of life. Not only does ASAMI provide a more comprehensive view of the disease, but it also provides stronger evidence for therapeutic decisions, the authors said.

“...ASAMI can serve as a tool for third parties to justify funding for JAK (Janus kinase) inhibitors,” the authors noted.²

The authors concluded that the development of such new tools has enabled clinicians and patients to more effectively manage the disease.¹

“Taken together, these tools provide a more complete picture of the impact of AA in both the adult and pediatric populations, facilitating individualized clinical treatment and clinical research for those affected by AA,” they said.

References:

1. Sun DI, Paller AS. Assessment of alopecia areata disease severity in pediatric patients. Pediatr Dermatol. 2025;42 Suppl 1(Suppl 1):31-35. doi:10.1111/pde.15830

2. ASAMI Consensus Survey Study Group, Moussa A, Bennett M, et al. The Alopecia Areata Severity and Morbidity Index (ASAMI) study: results from a global expert consensus exercise on determinants of alopecia areata severity. JAMA Dermatol. 2024;160(3):341-350. doi:10.1001/jamadermatol.2023.5869