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Alopecia Areata Update

Featuring Natasha Mesinkovska, MD, PhD |

Vice Chair, Clinical Research 
University of California Irvine
Irvine, CA

| Published February 22, 2024

Dermatology is entering what may be considered a golden age for alopecia areata (AA) with many new treatments available for adolescents and adults alike. While both genders are equally impacted by the condition, it appears that non-White individuals have a higher odds of developing the condition. The prevalence of AA has been increasing for the past 2 decades, and, while genetic predisposition cannot be discounted, Dr Mesinkovska indicated various triggers play a role in the initial loss of immune privilege of the hair follicle leading to destruction by cytotoxic T cells. 

She launched into the proliferation of treatments for AA, starting with JAK inhibitors bariticinib and ritlecitinib, both of which are approved for the condition. After a review of the JAK/STAT pathway, she covered the real-world application of JAK inhibitors in her practice, indicating the goal is 80% regrowth or a SALT20 in patients who started with complete loss. On baricitinib 4 mg daily, 1 in 3 patients achieve this goal by 36 weeks. Ritlecitinib targets JAK3, which has been shown to be present in skin and lymphoid organs and the TEC kinase family, which consists of 5 members that are involved in intracellular signaling downstream of surface receptors. Regardless, ritlecitinib shows similar results with 43% of patients achieving SALT20 by week 48. Eyebrow and eyelash growth, which for some patients can be more anticipated than scalp hair growth, is slightly higher in ritlecitinib than baricitinib between 40% to 44% compared to 31% to 34%, respectively. The last JAK inhibitor to be aware of is deuruxolitinib which has not yet achieved FDA approval. 

When discussing JAK inhibitors with her patients, Dr Mesinkovska does not hide the fact that treatment will need to be continued once hair growth is obtained, as stopping or skipping medication can lead to relapse of disease. Those with a disease duration of less than 4 years have the best chance of responding to treatment. The boxed warning for infections, mostly URIs, HSV, and VZV, as well as malignancy and cardiac events, though seen initially in an alternate population using tofacitinib, should be discussed. The hazard ratio for thrombosis is small but should be evaluated in patients with risk factors or those taking OCPs. Other medications to be on the lookout for are probenecid, or other OAT3 transporters, with baricitinib, and CYP1A2/CYP3A inhibitors with ritlecitinib. Isotretinoin and doxycycline can be administered concurrently, especially for those suffering from JAK-inhibitor-induced acne, which is fairly common. She concluded her presentation by presenting a few medication alternatives, including antihistamines, especially in those with atopic background, dupilumab for children or those who are JAK reluctant, and minoxidil in almost all patients to bolster results. 


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