With the recent approval of baricitinib and ritlecitinib, alopecia areata (AA) is one of the most talked-about diseases in dermatology today. During this session, Natasha A. Mesinkovska, MD, PhD, gave the audience the latest information on the pathogenesis and treatment of AA. Alopecia areata affects 2% of the global population, and the prevalence has been increasing over time. It has a complex pathogenesis, including genetics, environmental triggers, and loss of hair follicle immune privilege. Dr Mesinkovska discussed potential environmental triggers including infections, allergies, and vaccinations, including the COVID-19 vaccine. 

Moving on to treatments, Dr Mesinkovska dove into the data behind baricitinib and ritlecitinib. Baricitinib is a selective JAK1/2 inhibitor approved for severe AA in patients 18 years and older. Ritlecitinib is a JAK3/TEC inhibitor approved for severe AA in patients 12 years and older. Similar to JAK molecules, TEC kinases play a role in intracellular signaling leading to downstream immunity and inflammation. For those taking baricitinib 4 mg daily in Phase 3 clinical trials, 18% of patients achieved SALT20 (equivalent to 80% scalp coverage) at Week 16; 28% of patients achieved SALT20 at Week 24 and 32% to 35% of patients achieved SALT20 at Week 36. Ritlecitinib 50 mg daily led to 23% of patients achieving SALT20 at Week 24 and 43% of patients achieving SALT20 at Week 48 in clinical trials. 

To conclude, Dr Mesinkovska gave tips for real-world use of these medications. Once hair regrows with JAK inhibitors, treatment needs to continue otherwise hair will most likely be lost. Skipping pills can also result in worsening patchy AA. For patients who are hesitant about therapy, Dr Mesinkovska recommended trying the medication for 3 to 6 months instead of committing to long-term use. Regarding the black box warnings, Dr Mesinkovska discussed data showing low rates of major adverse cardiovascular events and malignancy but cautioned against use in current smokers, those with malignancy within the past 5 years, and those with prior episodes of venous thromboembolism.