Case-Based Insights Highlight Oral JAK Inhibitors for Alopecia Areata

At an interactive Dermatology Times Case-Based Roundtable event in Scottsdale, Arizona, faculty and advanced practice providers discussed real-world management of alopecia areata (AA), focusing on severity assessment, psychosocial impact, and integration of JAK inhibitors into practice. Karan Lal, DO, MS, FAAD, a double-board-certified pediatric and cosmetic dermatologist at Affiliated Dermatology, presented 3 core cases.

Case 1: 26‑Year‑Old Male with Patchy Scalp and Facial Hair Loss

In the first case, a 26‑year‑old man presented with patchy scalp involvement (SALT ~40–50) plus eyebrow and beard alopecia. The group emphasized that facial hair loss in men and eyebrows in women often drives quality-of-life impairment as much as scalp loss. After completing a severity assessment, most participants agreed this patient met criteria for severe AA and was an appropriate candidate for early systemic therapy, despite being “borderline” on scalp involvement percentage alone.

“How do you assess and address the psychosocial impact…? I don't necessarily think I ask. It's like something I can just feel in the room,” Lal told attendees. “For me, it's quality of life first and foremost.”

The discussion covered the limitations and risks and compared the expectations of other therapies like steroids and topical minoxidil. Practitioners of all levels are becoming increasingly comfortable with prescribing oral JAK inhibitors, although Lal and attendees noted the importance of counseling on lab monitoring, herpes zoster risk, lipids, cytopenias, and boxed warnings. The consensus was that in a young, highly impacted male with scalp and facial involvement, systemic JAK inhibition is now a reasonable first‑line strategy rather than a last resort.

“Historically, I've been a little bit scared of JAKs. So I think seeing this data…being down to 12 years of age makes you feel a little bit more comfortable,” one attendee shared.

Case 2: 29‑Year‑Old Female with Rapid Progression and a Big Life Event

The second case involved a 29‑year‑old woman whose SALT progressed from 10 to 76 over 18 months, with a rapid deterioration in the prior 3 months and a wedding scheduled in 9 months. There was no brow/lash involvement, but disease kinetics, a positive hair-pull test, and life circumstances were critical. Participants classified her as severe AA.

This case anchored a discussion on speed, safety, efficacy, and dosing convenience. All 3 FDA‑approved oral JAK inhibitors were reviewed, with emphasis on:

• Age indications (e.g., adolescent vs adult use)
• JAK selectivity (JAK1/2 vs JAK3/TEC) and lipid impact
• Dosing frequency (once vs twice daily)
• Need for CYP2C9 genotyping before prescribing one of the newer, twice‑daily agents

Efficacy curves showed that some agents demonstrate meaningful improvement by 12 weeks, which may be decisive for patients with a defined deadline. Lal and the group stressed explicit expectation-setting (peach fuzz by 3 months, fuller response closer to 6+ months) and shared decision‑making, especially around contraceptive and pregnancy plans. Despite concerns about treatment interruption for future pregnancy, most would offer systemic JAK therapy now, with the plan to stop when she begins trying to conceive, acknowledging the risk of relapse.

Case 3: 47‑Year‑Old Female with SALT 30 and Positive Hair‑Pull

The final case featured a 47‑year‑old woman with sudden patchy scalp loss (SALT 30) progressing over 6 months, a positive hair‑pull test, and irritation, plus minimal benefit from 6 weeks of OTC topical minoxidil. Attendees discussed distinguishing AA from other causes (telogen effluvium, scarring alopecias) via exam and, when needed, biopsy. They also addressed when to transition from “local/regional” management to systemic JAK inhibition, typically after 3 to 6 months of inadequate response or clear progression.

The group also reviewed comparative trial data across JAK inhibitors (SALT ≤20 and ≤10 at weeks 24–36, longer‑term extension outcomes) and practical triggers to switch within the JAK class (insufficient response at ~6 months, tolerability issues, or comorbidities like dyslipidemia).

“I think it's an exciting time...If I were a patient, there's 3 options. We know there's going to be more in the near future,” one participant noted.

Overall, participants reported growing confidence with JAK inhibitors, an increasing willingness to start systemic therapy earlier in the disease course, and appreciation for having multiple mechanistically distinct options to individualize care for patients with AA. Lal emphasized the openness of these Case-Based events, encouraging personalized learning on AA and beyond.

“I love doing these because it's so much fun...I get to talk, and I feel like I learn just as much as I do teach,” he said.