Alopecia Areata: Emerging Data and Treatment Approaches

Amy McMichael, MD

Wake Forest University School of Medicine

“You know, we have so much information exploding about JAKs now for literally everything, and alopecia areata is no different,” Amy McMichael, MD Professor, Dept of Dermatology Wake Forest University School of Medicine Winston-Salem, NC, said shortly after opening her presentation, The Mane Event: Alopecia Areata’s Latest Leaps, on Saturday at the 2025 Midwinter Clinical Hawaii Dermatology Conference being held in Hawaii, February 15-19.

McMichael offered a thorough review of the JAK inhibitors and their efficacy in treating alopecia areata but began her talk with an update on treatment of AA in patients of color and a quick pearl on use of minoxidil.

McMichael referred to 3 recent studies in adults and one in pediatric patients showing a relative increase in the incidence of AA among patients of color in the US, including Asian, Black, and Hispanic/Latino populations, compared to White patients. “When you see those patients, particularly those young patients who are of color, who have patchy hair loss, don't just write it off as tinea capitis,” she advised. Beware, too, of misdiagnosing hair loss as associated with lupus, which tends to be more prevalent in African American people. “Really look and be very sure if you don’t think you’re dealing with alopecia areata.”

McMichael provided a quick update on the integration of both topical and oral minoxidil in the management of hair loss. While it is widely used, though, she cautioned that the role of minoxidil in AA is still adjunctive rather than primary. She highlighted recent studies in both pediatrics and adults that found minoxidil can serve as a useful adjunct to JAK inhibitors. Patients are willing to accept potential hypertrichosis in non-target areas may benefit from its use.

JAK Inhibitors for Alopecia Areata

The landscape of JAK inhibitors is rapidly evolving, with increasing data supporting their use in AA. There are currently 3 JAK inhibitors approved for AA: ritlecitinib, which is the only JAK inhibitor approved for adolescents, ie, aged 12 years and older, and is taken once-daily as a 50 mg pill; baricitinib, available in 2 mg and 4 mg tablets for patients aged 18 years and older is also approved for rheumatoid arthritis and is being evaluated in atopic dermatitis; and deuruxolitinib, approved for adults but currently unavailable to patients. McMichael offered a topline look at the phase 3 clinical trials for all three.

For baricitinib, McMichael shared data from the BRAVE-AA1 and BRAVE-AA2 trials that demonstrated better efficacy with the 4 mg dose compared with 2 mg, although both doses significantly outperformed placebo. “And so this is a place where you have a shared decision making with your patient about how you're going to start. Are you going to start at the two? Are you going to start at four? Or are you going to start with the two and then increase quickly up to the four?” Clinicians should avoid stopping the drug, though, despite patients being concerned that it’s not working. “Because as we know…a lot of patients don't respond until six months, nine months,” sometimes it can take up to a year a year, McMichael noted. “So have the discussion, but don't take them off the drug until you've really gotten to that nine-to-12-month time frame.”

In the phase 2b/3 trial of ritlecitinib, the 50 mg dose showed the greatest efficacy. McMichael shared a compelling case of a 15-year-old patient with severe AA since age 6 years who had remarkable hair regrowth after 11 months on 50 mg daily. Deuruxolitinib, she explained, is not yet available for AA, but in early-phase trials showed a rapid onset of action, with significant separation from placebo as early as week 8, eight. An important note about this JAK is that CYP2C9 poor metabolizers may require monitoring or may be ineligible for deuruxolitinib. Future data will clarify the extent of this metabolic concern.

"How Long Do I Need This Drug?"

Patients frequently ask whether they will need to remain on JAK inhibitors indefinitely, and they are earnest in their desire to be finished with treatment. “You have to tell them, ‘Well, this is the time where you have to decide how much you want to keep your hair. Because what we know from long term research is when you go off of this medication,” hair loss recurs. “We don’t have a cure for AA, so you have to explain that to patients.” While some patients may enter remission, “we can't predict that, and there's no way to tell patients that they're going to be the ones that have that luck.

Monitoring to avoid adverse events is part of the plan with JAK inhibitors, McMichael said. The data say that we have to worry about these things, infections, thrombosis, MACE, malignancy. She recommends talking to patients and keeping it simple. “We don't want to make it complicated for patients. Tell them, okay, initially, we're just going to make sure you don't have TB or hepatitis. We'll do some baseline labs along with that, looking at your white blood cell counts, your red blood cell counts your LFTs, etc. And then, really, after that, it’s only about three times a year.” And if you present the situation in a non-threatening way, patients will respond to that.

Okay, we see the normal stuff that we see, headaches, COVID, nasal pharyngitis, upper respiratory tract infections, but none of the things that we're, you know, super worried about, none of the major serious AES with these patients.

A New Tool for Clinical Practice

McMichael wrapped up with a preview of a new Alopecia Areata Severity Scale, developed by a multidisciplinary group of dermatologists, pharmaceutical experts, and researchers with an aim to facilitate access to JAK inhibitors by better characterizing disease burden beyond percentage scalp involvement. Typical requirement for prior authorization is to demonstrate moderate to severe disease which is quantified as more than 50% scalp involvement. But the burden for patients is far greater, she said. “They have negative impact on their psychosocial health. They have noticeable eyebrow or eyelash involvement, which just changes the whole look of their face. And some don’t respond to initial treatment and have continuous active hair loss, even if scalp involvement is just less than 50%. The results of the scale, if any one of the features is present “will allow for a jump up to the next level” of treatment. I have been using it pretty regularly in my notes.”

Key Takehomes

• Recognize epidemiologic trends: AA incidence is increasing among patients of color—avoid misdiagnosing these cases as tinea capitis or lupus.
• Consider oral/topical minoxidil as an adjunctive therapy in appropriate patients.
• JAK inhibitors are effective and should be positioned as frontline therapy for severe AA.
• Baricitinib is approved for adults, and ritlecitinib is approved for adolescents.
• Euruxolitinib may offer a rapid onset of action pending further data.
• Long-term therapy is often necessary as discontinuation frequently results in relapse.
• Safety monitoring is straightforward: Labs every 4 months, with special considerations for older patients and those with malignancy, thrombosis, or hematologic abnormalities.
• Utilize the Alopecia Areata Severity Scale to support treatment access and insurance approvals.