The prognosis of alopecia areata (AA) is difficult to predict. Few studies report long-term follow-up of AA patients. The purpose of this study is to better assess the long-term evolution of AA and the possible relationship between disease severity and treatment response with long-term prognosis. One hundred ninety-one patients with AA who presented with a new diagnosis of AA between 1983 and 1990 were subsequently contacted by phone. Patients were queried regarding current disease status, treatments, and disease course. Severity of AA at first consultation ranged from mild (128 patients) to severe (63 patients). Fifty-five of 191 patients were affected by concomitant autoimmune or related inflammatory disease. Sixty-six of 191 patients were presently disease free (follow-up duration, 15-22 years; mean 17.74 years). These include 41 of 60 patients with S1 disease (68.3%), 22 of 68 patients with S2 disease (32.3%), 1 of 11 patients with S3 disease (9%), 1 of 14 patients with S4 disease (7.1%), and 1 of 11 patients with alopecia totalis (AT) (9.1%). Sixty-nine of 191 patients (36-1%) were presently affected by AT or alopecia universalis. There was a statistically significant tendency of severe patterns of AA to worsen over time. In children, 18 of 39 (13 with < or =S2 disease and 5 with > or =S3 disease) with AA had developed AT or alopecia universalis at long-term follow-up. In children, however, this trend was not statistically significant. Patients with severe AA who responded to topical immunotherapy seem to have a better prognosis than nonresponders. Follow-up was only performed by phone. Severity of AA at time of first consultation is an important prognostic factor. Response to therapy (topical immunotherapy) may be associated with better prognosis. In children, the prognosis is worse; our study found that AA worsens over time.