Clinical characteristics, subtype classification, and prognostic factors of ophiasis: A retrospective study of 150 patients with therapeutic implications

BACKGROUND: Ophiasis is an uncommon, clinical heterogeneous, and therapeutically challenging presentation of alopecia areata (AA). Evidence guiding meaningful subtyping and its implications for management remains limited. OBJECTIVE: To characterize the clinical, trichoscopic, and histopathologic features of ophiasis and evaluate a novel subtype classification for prognostic and management relevance. METHODS: A retrospective study of 150 patients with ophiasis was performed. Clinical, trichoscopic, and histopathologic data were collected and compared with patchy AA, acute diffuse and total alopecia, and alopecia universalis/alopecia totalis cohorts. A novel three-subtype classification of ophiasis based on scalp involvement patterns was proposed and evaluated its prognostic value. RESULTS: Ophiasis showed a female predominance, prolonged disease duration, and lower activity and regrowth rates than other AA subtypes. Trichoscopy demonstrated significant vellus hair involvement, abundant yellow dots, and minimal activity signs, while histopathology revealed minimal inflammation and increased telogen follicles, supporting chronicity. The 3 subtypes-typical ophiasis, ophiasis with patchy AA, and diffuse ophiasis-exhibited markedly different prognoses. Ophiasis with patchy AA showed comparatively favorable regrowth. Subtype classification independently predicted treatment response. LIMITATIONS: Sample size, retrospective design. CONCLUSION: Ophiasis is chronic and refractory. Our proposed classification system can accurately identify patients with poorer prognosis, guiding early intervention and stratified treatment.