Case 3: Alopecia Areata with Facial Involvement

Dr. Ungar reads Case 3, a 42-year-old man with a three-year history of alopecia areata. After a stable 18-month period, he developed rapid progression over eight weeks to 85 percent hair loss with new eyebrow and beard involvement. He has withdrawn from the gym and video calls, describes feeling unrecognizable, and gained little from six months of a high-potency topical corticosteroid and topical minoxidil.

Dr. Ungar says this presentation is common in his practice: patients with mild, stable, locally treated disease who flare after years. He highlights the word unrecognizable, since the effect on self-identity can be tremendous and underscores why the condition must be taken seriously.

On facial involvement, he explains that impact is not proportional to the amount of hair lost, particularly on the face. Even small beard patches or partial eyebrow or eyelash loss can weigh heavily. A patient with only 35 to 40 percent scalp loss plus facial involvement would still be severe in his view.

For baseline workup, Dr. Ungar follows the label nuances for each JAK inhibitor but orders one broad set of tests: tuberculosis, hepatitis viruses, a CBC, a complete metabolic panel, and a lipid panel. He checks thyroid function only when there is a reason. He also discusses herpes zoster vaccination and avoiding live vaccines.

For deuruxolitinib, CYP2C9 testing is added. A poor metabolizer with two copies of the variant may not be a candidate, which is uncommon. He orders it alongside the QuantiFERON test, and results typically return within several days.

In "JAK Inhibitors in Alopecia Areata: Treatment Goals, Safety Data, and Long-Term Management," Dr. Ungar will address treatment goals, safety evidence, and long-term management.