Conference summaries

Alopecia areata

New drugs for alopecia areata

Presented by: Prof. Spyridon Gkalpakiotis Department of Dermatovenereology, Third Faculty of Medicine and University Hospital of Kralovske Vinohrady, Prague, Czech Republic.
  • Based on better understanding of the pathophysiology of alopecia areata, a large number of targeted therapies are currently being investigated for alopecia areata.
  • Among these, JAK inhibitors appear to be highly promising agents for treatment of alopecia areata.

Alopecia areata affects both children and adults and hair of all colours. [1] Up to 66% of patients are younger than 30 years of age, and only 20% are older than 40 years, with no sex predilection. Alopecia areata is further associated with an increased overall risk of other autoimmune disorders: lupus erythematosus in 0.6% of patients, vitiligo in 4% and autoimmune thyroid disease in up to 28% of cases.

  • There are two primary option for management: [1]
    • use of an immunosuppressive regimen (preferable for patients with acute and rapidly progressing alopecia areata), or
    • an immune-deviation strategy that manipulates the intracutaneous inflammatory milieu (preferred for patients with the chronic, relapsing form).
  • At present, only two approaches reach the level of evidence-based medicine: intralesional injections of glucocorticoids and the induction of contact allergy.
  • The possibility to use JAK inhibitors for alopecia areata arose from an unusual case report in which a patient with plaque psoriasis being treated with tofacitinib experienced a reversal in alopecia universalis. [2]
  • We now know that Janus kinase-signal transducer and activator of transcription (JAK-STAT) is a signalling pathway that is crucial in maintaining the CD8+ NKG2D+ T cell inflammatory infiltrate which is typical of alopecia areata. [3]
  • At present, at least 3 JAK inhibitors are under investigation in alopecia areata: tofacitinib, baricitinib and ruxolitinib. [4]
  • In a study with tofacitinib in 66 patients (>50% scalp hair loss, alopecia totalis and universalis) treated with tofacitinib 5 mg twice daily, 32% of patients were intermediate responders (improvement in S ALT score ≥5% and ≤50%) and 32% were strong responders (changes in SALT score ≥50%).[4]
  • Patients with chronic alopecia areata were less likely to be good responders; drug cessation resulted in disease relapse in a mean of 8.5 weeks. [4]
  • A small study in 12 patients with moderate-to-severe alopecia areata on oral ruxolitinib, 20 mg twice per day, for 3–6 months, followed by 3 months follow-up off drug reported that after 6 months 75% of patients (9 of 12) had a strong response to treatment (defined as >50% hair regrowth). [4]
  • At the end of the treatment, shedding started 3 weeks after cessation of ruxolitinib. [4]
  • Most recently, the efficacy, side effects and durability of ruxolitinib was compared to tofacitinib in the treatment of severe alopecia areata. [5]
  • Both tofacitinib and ruxolitinib induced remarkable hair regrowth, with a mean change in SALT score of 93.8 ± 3.25 in the ruxolitinib group and 95.2 ± 2.69 in the tofacitinib group.
  • However, the ruxolitinib group showed a shorter duration for initial hair regrowth.
  • Baricitinib is an oral selective inhibitor of JAK1 and JAK2, approved for the treatment of rheumatoid arthritis.
  • To date only isolated case reports have been published on baricitinib in alopecia areata, although a placebo-controlled trial involving 725 subjects comparing baricitinib to placebo in moderate to severe alopecia areata is currently recruiting (NCT03570749).
  • Apremilast is a disease modifying antirheumatic drugs (DMARD) used in psoriasis; a small retrospective analysis on 15 patients showed that apremilast could be a potential treatment for refractory alopecia areata at doses lower than that approved for psoriasis; however, further study is needed. [6]
  • Fumaric acids inhibit T-suppressor cells and T-helper cells by the inhibition of the cytokines INF-γ, IL-2, IL-12 and TNF-α, and block ICAM and the proliferation of keratinocytes.
  • A retrospective analysis of 13 patients with various types of alopecia showed that those with alopecia totalis showed no response, while 67% those with alopecia universalis partially responded; 50% of alopecia areata patients had full regrowth of hair after a mean period of treatment of 5.2 months. [7]
  • However, relapse was seen after a mean of 3.3 months following cessation of therapy.
  • A number of other agents are in the early stages of investigation.
  • These include BNZ-1 (a selective and simultaneous inhibitor of cytokines IL-2, IL-9 and IL-15), tralokinumab (an IgG4 humanised monoclonal antibody that specifically binds IL-13) and dupilumab (a Th2 antagonist that blocks IL-4 receptor α, inhibiting IL-4 and IL-13). [4]
  • A large number of targeted therapies are currently under investigation for alopecia areata.

Key messages/Clinical perspectives

  • JAK inhibitors show particular promise for treatment of alopecia areata.



  1. Gilhar A, Etzioni A, Paus R. Alopecia areata. N Engl J Med. 2012 Apr 19;366(16):1515-25.
  2. Craiglow BG, King BA. Killing two birds with one stone: oral tofacitinib reverses alopecia universalis in a patient with plaque psoriasis. J Invest Dermatol. 2014 Dec;134(12):2988-90.
  3. Phan K, Sebaratnam DF. JAK inhibitors for alopecia areata: a systematic review and meta-analysis. J Eur Acad Dermatol Venereol. 2019 May;33(5):850-6.
  4. Ocampo-Garza J, Griggs J, Tosti A. New drugs under investigation for the treatment of alopecias. Expert Opin Investig Drugs. 2019 Mar;28(3):275-284.
  5. Almutairi N, Nour TM, Hussain NH. Janus kinase inhibitors for the treatment of severe alopecia areata: An open-label comparative study. Dermatology. 2019;235(2):130-6.
  6. Taneja N, Gupta S. Apremilast is efficacious in refractory alopecia areata. J Dermatolog Treat. 2019 May 6:1-3.
  7. Niculescu L, Heppt MV, Varga R, et al. Retrospective analysis of the application of fumaric acid esters in 13 patients with alopecia areata. Eur J Dermatol. 2018 Jun 1;28(3):376-7.

Presenter disclosure information: S Gkalpakiotis: None disclosed.

Medical writer: Patrick Moore, PhD

Reviewer: Martina Lambertini, MD

Local reviewers: Martina Lambertini, MD (Italian); Alain Brassard, MD (French); Jorge Moreno González, MD (Spanish); Swen Malte John, MD, PhD (German); Marcelo Arnone, MD (Portuguese)

Scientific Editor: Prof. Brigitte Dréno, MD



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Efficacy and safety of a 52-week, randomized, double-blind trial of ruxolitinib cream for the treatment of vitiligo

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New drugs for alopecia areata

Presented by: Prof. Spyridon Gkalpakiotis, Department of Dermatovenereology, Third Faculty of Medicine and University Hospital of Kralovske Vinohrady, Prague, Czech Republic.


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Systemic treatments of non-melanoma skin cancer

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