Alopecia Areata Cases Define a Path to Systemic Care

By Daniel Okafor

By week 8, deuruxolitinib 8 mg twice daily yielded a significant placebo difference in the proportion of adults with alopecia areata achieving SALT of 20 or less, based on two phase 3 randomized trials.

The deck data came from THRIVE-AA1 and THRIVE-AA2, published in JAAD in 2024 and 2026, respectively. THRIVE-AA1 was randomized and controlled; THRIVE-AA2 was randomized, double-blind, and controlled. Goh presented that evidence during a Los Angeles Dermatology Times Case-Based Roundtable.

At the roundtable, 9 of 11 clinicians named extent of scalp involvement as the leading trigger for systemic escalation. Carolyn Goh, MD, a dermatologist and clinical professor of dermatology at UCLA, led the session through 3 cases covering time-sensitive goals, psychosocial burden, and extensive disease with facial involvement.

Three FDA-approved oral Janus kinase inhibitors framed the discussion: deuruxolitinib (Leqselvi; Sun Pharma), ritlecitinib (Litfulo; Pfizer), and baricitinib (Olumiant; Eli Lilly). The program focused on individualizing care.

What pushes a patient toward systemic treatment?

Case 1 featured a 33-year-old man with 45% scalp hair loss. Four months of a topical corticosteroid had produced minimal improvement. He wanted maximal regrowth before a wedding in 6 months.

One attendee said no one in their experience responds to local treatment. Another reported success with intralesional injections for localized mild disease. Eight of 10 attendees rated speed of response moderately influential.

Goh reviewed the Severity of Alopecia Tool, or SALT, and the Alopecia Areata Scale. The latter is not validated. Drug indications specify severe disease without a percentage, so she said secondary criteria can support a severe classification in the note.

Extent alone did not settle the decision. Goh compared JAK inhibition to a sledgehammer hitting a nail in a wall. Treatment is often lifelong because alopecia areata tends to flare.

The week-8 finding gave attendees a concrete speed benchmark, but it did not make systemic therapy automatic when involvement remained limited and the risk-benefit balance uncertain.

In her practice, Goh starts baricitinib at 4 mg for truly severe disease. She uses 2 mg for moderate disease or when side effects concern her.

Speed shaped the wedding case, but severity and individual risk still set the boundary.

How does psychosocial burden affect the treatment target?

Case 2 involved a 29-year-old woman whose scalp hair loss increased from 21% to 36% over 3 months. She worried about progression, avoided social events, and wore head coverings at work. Rosemary oil and a topical corticosteroid had produced minimal regrowth.

One attendee classified her as moderate. Goh centered the discussion on quality of life and said: “We’re treating patients to be well.” That moved the treatment target beyond hair count alone.

Several attendees said the burden falls harder on women. Goh noted that men may struggle because they feel they are not supposed to be bothered by hair loss. Wigs and makeup are more socially accepted for women, she added.

Goh presented patient-reported outcomes from the deck. Observational data showed Skindex-16 scores falling from 48.4 to 30.9 at week 24 with ritlecitinib 50 mg, and from 57.1 to 30 at week 48 with baricitinib 4 mg.

The ritlecitinib data came from a 24-week multicenter real-world study in severe alopecia areata, published in the American Journal of Clinical Dermatology in 2026. Baricitinib effectiveness and safety results covered 48 weeks in severe disease and appeared in the Journal of the European Academy of Dermatology and Venereology in 2026.

One attendee defined success beyond SALT reduction as self-confidence and patients feeling better.

Clinicians would wait at least 3 to 6 months before calling a JAK inhibitor a failure, with some willing to wait a year. Goh said six months was reasonable when there was no response. In a poll, 7 of 9 would switch to another JAK inhibitor.

Regrowth and confidence moved together in this case, so neither served as a stand-alone measure of success.

What safety workup should precede a JAK inhibitor?

Case 3 presented a 42-year-old man with 85% scalp hair loss. New eyebrow and beard involvement appeared after 6 months of clobetasol and topical minoxidil. His baseline CBC was unremarkable. Hepatitis and tuberculosis screening were negative. CYP2C9 genotyping showed a normal metabolizer.

Attendees suggested repeating laboratory tests 1 to 2 months after initiation, then every 6 to 12 months. Goh recommended zoster vaccination for all patients starting a JAK inhibitor. These drugs generally need not be held for vaccination, except for live vaccines used for travel.

Four of 9 attendees said CYP2C9 results only determine whether deuruxolitinib is appropriate. Goh agreed. Testing takes about 1 week, and the pharmacist cannot dispense until the result returns. Another attendee said a sales representative had called the ordering process very easy, although the attendee had never placed an order.

One attendee said counseling is difficult after previous studies raised MACE and malignancy concerns. Goh outlines cardiovascular, thromboembolic, malignancy, and infection risks with every patient, then tailors the discussion to individual risk factors.

Stopping treatment requires a separate plan because flares are likely. Goh said: “Most patients do respond again if they stop and then get back on.” In the closing poll, 6 of 13 selections favored best practices for monitoring and safety, while 5 reflected existing comfort with JAK inhibitors.

The remaining questions concern sequence rather than speed. Goh asked whether oral minoxidil or systemic steroids belong at initiation or as rescue. Her practical view was that JAK inhibitors alone work relatively quickly for alopecia areata.

Future guidance should resolve whether oral minoxidil or systemic steroids belong at initiation or as rescue, while defining monitoring for treatment that may last years.