New Visual Scoring Tool Extends Alopecia Areata Assessment Beyond the Scalp

Eyebrows, eyelashes, and the beard often carry as much of alopecia areata's visible toll as the scalp does, yet the field's standard severity score never looks at any of them.¹ A newly validated scoring instrument aims to close that gap without asking clinicians to abandon the tool they already trust.

A Gap in the Standard Severity Score

The Severity of Alopecia Tool (SALT) remains the field's standard for measuring scalp involvement in alopecia areata (AA), but it excludes the eyebrows, eyelashes, and beard, and it does not adjust for concomitant androgenetic alopecia (AGA). SALT also depends on unguided visual estimation, which contributes to variability between observers scoring the same patient.

Eyebrow and eyelash loss ranks second only to scalp hair loss in the distress patients with AA report, and it carries functional consequences such as reduced eye protection from moisture and debris, a commentary in the British Journal of Dermatology noted.² Patients often go to lengths to conceal brow and lash loss specifically, a pattern that scalp-only scoring cannot capture.

Two-Phase, Single-Center Validation

The Visual Extension of SALT (VESALT) provides structured panels of reference images covering graded involvement of the scalp, eyebrows, eyelashes, and beard.¹ The scalp series reflects patchy, focal, ophiasis, reticulate, and diffuse patterns, letting raters fold pattern recognition into scoring, while a graded density scale accounts for partial regrowth during follow-up. Separate AGA panels and a correction formula isolate autoimmune hair loss from hormonal thinning in patients with both conditions.

Researchers at Ghent University Hospital in Belgium tested the tool in 2 phases. First, 3 observers independently scored both SALT and VESALT in 10 consecutive patients examined in person. Second, 11 raters, including dermatologists, dermatology trainees, research staff, and general practitioners, scored a photographic dataset of 53 cases representing a range of phototypes and severities. Most images were not standardized, reflecting common clinical practice, though beard photographs were standardized for a second scoring round.

Reliability Matched or Exceeded SALT

VESALT produced excellent interrater reliability throughout the validation: an intraclass correlation coefficient (ICC) of 0.975 in the live cohort and 0.953 and 0.948 in the first and second rounds of photographic scoring, respectively. Intrarater reliability was significantly higher for VESALT than for SALT (ICC, 0.957 vs 0.925), and the smallest detectable intrarater difference was lower for VESALT (14.7% vs 22.52%), though the clinical relevance of that gap needs further study. The correlation between mean SALT and mean VESALT scores exceeded 0.99, and Bland-Altman analysis showed no systematic or proportional bias between the 2 instruments.

Eyebrow and eyelash scoring reached ICCs above 0.85 in both live and photographic evaluations. Beard scoring reached an ICC of 0.865 in live assessments and 0.947 once images were standardized, and the AGA-adjusted AA score reached an ICC of 0.967. Pattern identification agreement across raters was 94%, and observers rated VESALT as more user-friendly and intuitive than SALT.

“Because VESALT is numerically interchangeable with SALT, it can be used with established endpoints such as SALT50 and SALT90,” the researchers wrote. “The extended anatomic coverage and structured reference panels may allow more consistent scoring in multicentre studies.”

Limitations and Next Steps

The validation is limited by its monocentric design and by the small size of the live cohort, and the authors cautioned that reliability differences between SALT and VESALT should be interpreted with caution as a result. Not all photographic images were standardized during the first scoring round, though the researchers noted this reflects common clinical practice; beard images were standardized for the second round after early inconsistency.

Time to completion, learning curves, and responsiveness to treatment, a property essential for clinical trials, will be addressed in future work, alongside a paper version and an online VESALT calculator already available to support teledermatology and a longer-term goal of automated, AI-based scoring. With the extended anatomic coverage that regulators, including the U.S. Food and Drug Administration (FDA) and European Medicines Agency (EMA), increasingly expect from outcome measures, VESALT gives clinicians, trial sponsors, and patients a way to track eyebrow, eyelash, and beard involvement that SALT alone has never captured.

References

1. Speeckaert R, Belpaire A, van Caelenberg E, Dewaele D, Vanden Broucke L, Hoorens I, Neudakh L, Van Maelsaeke E, Speeckaert M, van Geel N. Development of a visual extension of the Severity of Alopecia Tool (VESALT) for alopecia areata. J Eur Acad Dermatol Venereol. 2026;40:e696-e698. doi:10.1111/jdv.70373
2. Fu JM, Goh C. Beyond universalis: eyebrow and eyelash loss in patients with alopecia areata. Br J Dermatol. 2025;193(2):198. doi:10.1093/bjd/ljaf139