Global Guidelines in Dermatology Mapping Project (GUIDEMAP): a systematic review of alopecia areata clinical practice guidelines

Management of alopecia areata (AA) remains challenging, with high relapse rates, few available treatments, and limited data on the efficacy and safety of current treatments. In this study, we found a disproportionately low number of AA clinical practice guidelines (CPGs) available compared with those for other common dermatological conditions, along with an under-representation of AA CPGs from Asia, South America and Africa. We found that the majority of current AA CPGs were developed with low methodological quality, in particular, in the following domains: rigour of development, stakeholder participation and applicability. Introduction Alopecia areata (AA) is a nonscarring alopecia with an estimated global prevalence of 2% and limited data on the efficacy of current treatment. Clinical practice guidelines (CPGs) provide recommendations based on best available evidence. It is unclear how many AA CPGs are available globally. Aim To systematically search for and identify CPGs on AA and to critically appraise their quality using validated tools. Methods We performed a literature search to identify CPGs published between October 2014 and April 2021, using the following databases: MEDLINE, Embase, National Institute for Health and Care Excellence (NICE), Guidelines International Network, Emergency Care Research Institute guidelines trust, Australian CPGs, Turning Research Into Practice database and DynaMed. The systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Three critical appraisal tools were used: Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, Lenzer's red flags and United States Institute of Medicine's (IOM) criteria of trustworthiness. Results In total, six AA CPGs from seven manuscripts (one CPG was in two parts published in separate papers) were included. The majority (four of six) of the CPGs focused on treatment. Four CPGs (total of five papers) were in English and two CPGs were only available in the original language (one Russian and one Japanese). All AA CPGs demonstrated low quality in several domains in the AGREE II appraisal, including stakeholder involvement and applicability, with the latter being deemed the worst domain for all CPGs, with an average of 29%. The mean (SD) number of Lenzer's red flags for the included CPGs was 3.4 (1.5) out of a total of 8 possible red flags, while the IOM criteria showed 1.6 (0.8) 'fully met' criteria and 3.1 (1.2) 'not met' out of a total of 9 criteria. Conclusion We found a limited number of AA CPGs, all of which had significant methodological deficiencies. We encourage guideline development groups to use validated checklists/tools to develop reliable and trustworthy CPGs.