12-phase flow (12)

1. 1FRAME
   Frame as a CHRONIC, unpredictable, relapsing T-cell-mediated NON-SCARRING autoimmune hair-loss disease (immune-privilege collapse) managed on an extent/SALT/age-stratified ladder with psychological support as a first-class outcome — NOT a one-off cosmetic complaint. EVERY patient is screened for the autoimmune (thyroid/vitiligo/T1DM) + atopic comorbidity cluster and for depression/anxiety. The not-to-miss is SCARRING (cicatricial) alopecia and tinea capitis masquerading as AA.
   advance: chronic relapsing non-scarring framing set; comorbidity + psychosocial + scarring/tinea escape routes noted
2. 2ENTRY
   Recognise abrupt well-circumscribed non-scarring patchy loss with trichoscopy pivots vs the extensive/AT/AU/ophiasis entry vs the severe-psychosocial-distress entry; capture extent + pattern (SALT estimate) up front as the primary severity axis.
   inputs: extent_pattern_and_salt_estimate
   actions: workup.chronic_pruritus
   advance: entry trigger present; extent + pattern (SALT estimate) recorded
3. 3CONTEXT
   Build the diagnosis + treatment context: confirm non-scarring with PRESERVED follicular ostia + trichoscopy (exclamation-mark hairs, yellow/black dots, broom hairs, regrowing vellus; positive peripheral pull-test in active disease; nail pitting), disease duration + progression tempo (recent limited = high spontaneous regrowth; long-standing AT/AU = lower), the autoimmune (thyroid/vitiligo/T1DM) + atopic comorbidity screen, and a structured psychosocial + depression/anxiety assessment (a core, not optional, axis).
   inputs: nonscarring_features_preserved_follicular_ostia, disease_duration_and_progression_tempo, autoimmune_atopic_comorbidity_screen, psychosocial_burden_and_mood_screen
   actions: workup.chronic_pruritus
   advance: non-scarring AA supported by trichoscopy; duration/tempo + comorbidity + psychosocial context established
4. 4RED_FLAGS
   Tinea capitis (scaling, broken hairs, kerion, occipital lymphadenopathy, child) → KOH/fungal culture + systemic antifungal, do NOT immunosuppress (route the dermatophyte engine). SCARRING/cicatricial alopecia (LOSS of follicular ostia, perifollicular erythema/scale, atrophy — LPP/DLE/CCCA) → urgent biopsy; irreversible follicular destruction if mistaken for AA. Severe psychosocial distress / suicidality → mental-health escalation + accelerate therapy. Rapidly progressive extensive loss → expedite systemic-ladder workup.
   inputs: scalp_scaling_broken_hairs_or_pruritus, scarring_features_lost_ostia_perifollicular_change
   actions: panel.cbc
   advance: tinea / scarring alopecia / severe distress / rapid progression screened and escalated/routed if present
5. 5INITIAL_WORKUP
   AA is a clinical + trichoscopic diagnosis — no test confirms it. Targeted workup is for (a) the comorbidity screen (TSH/thyroid function; consider vitiligo/T1DM/atopy review) and (b) systemic-ladder readiness before an oral JAK inhibitor: CBC, LFT, lipids, latent-TB + HBV/HCV, zoster/immunisation review. Scalp biopsy ONLY for diagnostic uncertainty or to exclude scarring alopecia; KOH/fungal culture if tinea is plausible.
   inputs: tsh_thyroid_function, cbc_with_differential, lft, latent_tb_hbv_hcv_zoster_immunisation
   actions: panel.cbc, panel.lft, panel.thyroid, panel.renal
   advance: comorbidity screen done; pre-JAK safety labs + TB/hepatitis drawn if systemic escalation likely; biopsy only if indicated
6. 6BRANCHING_WORKUP
   Non-scarring-alopecia decision tree: preserved ostia + exclamation-mark hairs + abrupt patch → AA; scaling + broken hairs + child + KOH/culture+ → tinea capitis (route derm.tinea-dermatophytosis.core.v1); LOST ostia + perifollicular scale/erythema/atrophy → scarring alopecia (LPP/DLE/CCCA) — BIOPSY, do not treat as AA; bitemporal/vertex thinning + miniaturised hairs + preserved density gradient → androgenetic alopecia (different management); diffuse shed + trigger ~3 mo prior + positive diffuse pull-test → telogen effluvium; irregular patches with broken hairs of varying length / trichophagia → trichotillomania; moth-eaten patchy loss + RPR/TPPA → syphilitic alopecia; diffuse anagen shed on chemotherapy → anagen effluvium; new drug timeline → drug-induced telogen/anagen effluvium.
   inputs: scarring_features_lost_ostia_perifollicular_change
   actions: workup.chronic_pruritus
   advance: AA confirmed clinically/trichoscopically OR an alternative alopecia assigned + routed; scarring alopecia and tinea actively excluded
7. 7DIFFERENTIAL
   Terminal non-scarring-alopecia differential with named pivots: alopecia areata (abrupt well-circumscribed patch + preserved ostia + exclamation-mark/yellow-dot trichoscopy + nail pits + peripheral pull-test pivot) vs androgenetic alopecia (patterned bitemporal/vertex + follicular miniaturisation + gradual pivot) vs telogen effluvium (diffuse global shed + trigger 3 mo prior + diffuse positive pull-test pivot) vs tinea capitis (scaling + broken hairs + KOH/culture+ pivot — route derm.tinea-dermatophytosis.core.v1) vs trichotillomania (irregular, varying-length broken hairs + behavioural pivot) vs SCARRING alopecia / LPP-DLE-CCCA (LOSS of follicular ostia + perifollicular change + biopsy pivot — NOT AA) vs traction alopecia (marginal + tension-hairstyle pivot) vs secondary-syphilis moth-eaten alopecia (RPR/TPPA pivot) vs anagen effluvium (chemotherapy timeline pivot) vs drug-induced telogen effluvium (new-drug temporal pivot).
   advance: single best diagnosis selected; scarring alopecia + tinea actively excluded; pattern (patchy vs AT/AU/ophiasis) assigned
8. 8RISK_STRATIFICATION
   Severity = SALT (0–100) × pattern × duration × eyelash/eyebrow/nail involvement × psychosocial impact (SALT / Alopecia Areata Scale scored clinically — schema-blocked as registry calculators, captured narratively). Limited (SALT low, <25–50%, recent-onset, no AT/AU) → topical/intralesional + watchful waiting (high spontaneous regrowth). Extensive/severe (SALT ≥20, ≥50%, AT/AU, ophiasis, rapidly progressive, or refractory to local therapy, or severe psychosocial burden) → systemic oral-JAK consideration first-line. Severe psychosocial distress upgrades urgency independent of SALT.
   inputs: extent_pattern_and_salt_estimate, psychosocial_burden_and_mood_screen
   advance: limited vs extensive/severe tier + SALT-based escalation decision + psychosocial-urgency modifier assigned
9. 9TREATMENT
   Extent/SALT/age-stratified ladder + psychological support always. Limited (SALT low / recent-onset / no AT-AU): intralesional triamcinolone (adult patchy 1st-line), high-potency topical corticosteroid (pediatric / extensive-but-not-systemic), topical minoxidil adjunct, topical immunotherapy DPCP/SADBE for chronic refractory patchy, anthralin; watchful waiting is legitimate for limited recent-onset (high spontaneous regrowth). Extensive/severe / AT-AU / ophiasis / rapidly progressive / refractory / high psychosocial burden: oral JAK inhibitor — baricitinib (adult), ritlecitinib (≥12 y incl. adolescents), deuruxolitinib. Counsel ~6 mo to judge response (slow regrowth) and relapse-on-discontinuation. Adjuncts/non-pharm: wigs/camouflage + psychological support (core QoL outcome), eyelash/eyebrow options. Comorbidity gating: pregnancy/lactation → avoid JAK (topical/intralesional, limited data); thrombotic/CV/malignancy/infection risk → JAK risk-stratify or defer; AVOID chronic systemic corticosteroids (relapse on withdrawal + cumulative harm).
   inputs: pregnancy_lactation, age, thrombotic_cardiovascular_malignancy_infection_risk, creatinine
   advance: extent-appropriate ladder step started; psychological support offered; agent gated on age/pregnancy/thrombotic-CV/comorbidity; ~6-mo response + relapse counselled
10. 10DISPOSITION
    Entirely outpatient/derm-clinic — AA is not an admission disease. Oral-JAK initiation/monitoring via dermatology; route tinea OUT to derm.tinea-dermatophytosis.core.v1, scarring alopecia to scalp-biopsy/cicatricial-alopecia care; refer mental-health for significant depression/anxiety/suicidality; pediatric extensive disease → pediatric-dermatology + ritlecitinib-eligibility pathway.
    inputs: psychosocial_burden_and_mood_screen
    advance: disposition documented; outpatient derm follow-up + mental-health/peds referrals as indicated; mimics routed OUT
11. 11MONITORING
    Disease: SALT response at 3 / 6 / 9 mo (regrowth is slow — counsel ~6 mo before judging adequacy; meaningful response often by ~3–6 mo on JAK). Drug safety on oral JAK: CBC + LFT + lipids at baseline then periodically; VTE/MACE/serious-infection/herpes-zoster/malignancy vigilance; CK/acne class effects. Psychosocial: re-screen mood — sustained regrowth improves HRQoL/anxiety/depression (BRAVE-AA QoL data). Counsel relapse on discontinuation (common, especially AT/AU).
    inputs: lipid_panel, cbc_with_differential
    actions: panel.cbc, panel.lft
    advance: SALT response assessed at 3/6/9 mo; oral-JAK class safety labs on schedule; mood re-screened
12. 12FOLLOWUP
    Chronic-disease maintenance: counsel the unpredictable relapsing course + realistic regrowth expectations (lower for long-standing AT/AU; high spontaneous regrowth for limited recent-onset), relapse-on-JAK-discontinuation, lifelong autoimmune (thyroid/vitiligo/T1DM) + atopic + mental-health surveillance, wig/camouflage + peer-support signposting, eyelash/eyebrow care, sun/ocular protection where brows/lashes lost, and step-up/step-down criteria. Dermatology continuity for any systemic agent; re-evaluate diagnosis (biopsy) if the course is atypical or scarring features emerge.
    inputs: autoimmune_atopic_comorbidity_screen, psychosocial_burden_and_mood_screen
    actions: workup.chronic_pruritus
    advance: course/relapse + regrowth-expectation counselling + comorbidity + mental-health surveillance + camouflage/support documented