Managing Eyebrow & Eyelash Loss in Alopecia Areata: Emotional Impact & Treatment Insights
Clinical Summary
- High Impact, Low Coverage: Eyebrow and eyelash loss is psychologically and functionally significant—more visible, harder to conceal, and critical for eye protection compared to scalp hair loss.
- Treatment Advances Drive Awareness: Historically overlooked due to lack of effective options, but now gaining attention thanks to JAK inhibitors showing 25–45% regrowth efficacy in clinical trials.
- Trials Now Include Targeted Outcomes: Clinical trials assess eyebrow/eyelash regrowth using validated 4-point scales; responders must show ≥2-point improvement.
- Patient Quality of Life: Regrowth in these areas significantly improves patient satisfaction—even when scalp regrowth is incomplete.
- Clinical Practice Recommendations:
- Evaluate and document eyebrow/eyelash involvement at baseline and follow-up.
- Use photography to monitor progress.
- Emphasize these regions as meaningful, treatable targets.
- Future Directions: AI-driven image analysis may enhance outcome measurement; continued inclusion in trial endpoints is expected.
Reviewed by Riya Gandhi, MA, Associate Editor of Immunology Group
In an insightful conversation with Dr Melissa Piliang, we explore how eyebrow and eyelash loss affects patients’ quality of life, advancements in treatment options, and how new clinical trials are offering hope for patients seeking eyebrow and eyelash restoration.
Melissa Piliang, MD, FAAD, is the Chairman of the Department of Dermatology at Cleveland Clinic.
Transcript
Can you discuss the psychological and emotional impact of eyebrow and eyelash loss in patients with alopecia areata, and how does it differ from scalp of hair loss?
Dr Piliang: So eyebrows and eyelashes are really important. They are front and center when we meet somebody, and in contrast to the scalp hair, they're very hard to replicate or replace. So even if you get tattooed eyebrows, even if you draw them in, they still flat rather than three dimensional. And it is really hard. Patients can get very good wigs that can cover their scalp and really are very, very effective, but it's much harder to cover eyebrows and eyelashes. And so I think that psychological impact is really important. Number one, the other piece of eyebrows and eyelashes, they are actually functionally important. So eyebrows serve as a barrier to protect the eye, so they keep sweat and anything that you put on your scalp in your forehead from running into your eyes. So if you don't have eyebrows and you put on sunscreen and you go out and play basketball and get all sweaty, or you go out and mow the lawn and you get sweaty, all that sunscreen and everything that's on your forehead runs into your eyes and burns.
So we really have to think about not just the psychosocial impact of it, but also the functional impact. It's the same thing with eyelashes. My patients who don't have eyelashes tell me that they get more grit and dirt in their eyes. They get more eye irritation, they get more eye tearing and watering, and they even feel like if they roll over in the night that it irritates their eye because they don't have that eyelash there to protect them. So it's very important for people to understand the importance of eyebrows and eyelashes and that treating them is very worthwhile.
Why has the loss of eyebrows and eyelashes in alopecia areata been historically underappreciated, and what changes have you seen in its recognition in recent years?
Dr Piliang: I think some of it comes from just not having good treatments for alopecia areata, and certainly not having great treatments for eyebrows and eyelashes and the scalp hair is very obvious and was the focus for a long time. And so people get injections in their scalp. My office does injections and eyebrows, but it's much harder and much more painful for patients. In eyelashes, we had very limited treatment that we could do. So I think that's part of the reason there just weren't good treatments and people, our patients would find ways to cover cosmetically as well as they could. Now, why is it suddenly becoming more popular or why is it suddenly being discussed more? I think it's because now we can treat it and we have good, safe options both topically and orally that can really help grow the eyebrows and eyelashes. And so it's part of the conversations we have. And I have patients who go on a JAK inhibitor and they only grow back eyebrows and eyelashes and they're still very happy because eyebrows and eyelashes are incredibly important.
How are clinical trials addressing the issue of eyebrow and eyelash loss in alopecia areata? Are there specific outcomes being measured in these areas?
Dr Piliang: I think the clinical trials actually have really helped with the increased emphasis on eyebrow and eyelash involvement in alopecia areata. The eyebrow and eyelash regrowth was one of the outcomes that was monitored, and the scale that was used to determine success was a four point scale, going from full eyebrows or eyelashes to minimal patchy loss to significant loss, but still a few eyebrow eyelashes or to complete loss. And to be considered responders in the trials, patients had to go from either complete loss or near complete loss and move up two points. So if they had complete loss, they either had to have near complete regrowth or full eyebrows. If they had minimal eyebrows or eyelashes, they had to go to complete regrowth to be able to be considered a responder in the trial.
From a clinical standpoint, how do you assess the importance of restoring eyebrow and eyelash growth in your patients with alopecia areata?
Dr Piliang: So I always look at eyebrows and eyelashes, and I document how much is regrown, where we started, and how much we've regrown. I do a lot of photos of my patients, so I have before-and-after photos, so we can use that also to track their eyebrows and eyelashes.
What role do treatments such as JAK inhibitors or biologics play in regrowing eyebrows and eyelashes for alopecia areata patients? Is there evidence supporting their efficacy?
Dr Piliang: Yes, so there is, in the clinical trials, the efficacy for eyebrows and eyelashes mirrored the efficacy for scalp hair. So somewhere between 25% and 45% of patients, depending on the dosage of the medication and the drug would regrow their eyebrows and eyelashes. So incredibly important for patients to have access to these medications for eyebrows and eyelashes.
In your experience, how does the restoration of eyebrow and eyelash hair influence overall patient quality of life and treatment satisfaction?
Dr Piliang: I think patients are very happy to have hair back, and they are especially happy to have eyebrows and eyelashes back because like I mentioned earlier, you can cover your scalp hair with a wig, but it's very difficult to replicate eyebrows and eyelashes in a natural way. And they serve the functional purpose like we talked about also. And so I think patients are incredibly happy to have eyebrows and eyelashes back.
Do you foresee any changes in future clinical trial designs to better capture the impact of eyebrow and eyelash loss in alopecia areata, and what should be prioritized moving forward?
Dr Piliang: I expect that clinical trials will continue to include eyebrows and eyelashes as an outcome. I think if we had a way, maybe with photos to capture and maybe AI to capture percent regrowth in a more specific way, that might be helpful, and it would be great if we could see that in clinical trials moving forward.
Are there any tips or insights you would like to share with your dermatologist colleagues regarding the impact of eyebrow and eyelash loss in alopecia areata?
Dr Piliang: So I would just emphasize that eyebrows and eyelashes are incredibly important for patients. They're important for the function of protecting their eyes. They're also important for emotional, social feelings, and well-being, and treating eyebrows and eyelashes is worthwhile and very important.
