Clinicians Debate JAK Inhibitor Selection in Alopecia Areata

Terry Faleye, DMSc, MPAS, PA-C, led a Dermatology Times Case-Based Roundtable dinner program in Houston, Texas, on individualizing alopecia areata (AA) care. The September 28, 2026, program reviewed 3 patient cases, exploring how disease severity, treatment goals, psychosocial burden, efficacy, and safety considerations can influence clinical decision-making.

Time-Sensitive Regrowth Goals Drive Treatment Pace

The first case involved a 33-year-old man with a 2-year history of AA and 45% scalp hair loss. He was getting married in 6 months and wanted to regrow as much hair as possible before the wedding. He had experienced minimal improvement after 4 months of topical corticosteroid treatment.

Attendees said they typically gauge disease severity using the percentage of scalp involvement and the presence of facial hair loss, rather than routinely calculating a formal Severity of Alopecia Tool (SALT) score. The discussion also turned to the potential role of stress, with several clinicians describing it as an important consideration when evaluating patients and their response to treatment.

“You have to really assess the patient’s stress levels in any of these cases. I don’t care if they’re on the strongest JAK, if they’re stressed out and their cortisol hormones escalate, they’re not going to respond,” one attendee said.

Faleye said framing stress as a potential disease trigger rather than a personal failing can help clinicians approach the topic more constructively with patients.

“I like that, because it’s a softer landing versus the ‘get your life together’ type deal,” Faleye said.

Given the patient's time-sensitive goal and limited response to topical treatment, the discussion moved toward initiating systemic therapy with a Janus kinase (JAK) inhibitor.

Faleye reviewed efficacy data for the available agents, including pooled findings from the phase 3 THRIVE-AA1 and THRIVE-AA2 trials. Among patients treated with deuruxolitinib 8 mg twice daily, 31% achieved a SALT score of 20 or less at week 24 compared with 0.8% of patients receiving placebo (P<.0001).

Several attendees said they had observed relatively rapid responses to deuruxolitinib in clinical practice, although another clinician noted that the clinical trial efficacy data appeared broadly comparable across the available agents.

The discussion highlighted the importance of aligning treatment selection and expectations with the patient's individual goals, particularly when a major life event creates a desired timeline for visible regrowth.

Psychosocial Burden Guides Severity Classification

The second case involved a 29-year-old woman with patchy scalp hair loss that had progressed from 21% to 36% over 3 months. Although she had no eyebrow or eyelash involvement, she reported significant anxiety about continued progression, had begun avoiding social events, and was wearing head coverings at work.

Attendees discussed how scalp involvement alone may not capture the full burden of AA. Under the Alopecia Areata Scale, psychosocial impairment is a secondary criterion that can increase the severity classification beyond what would be indicated by the percentage of scalp hair loss alone.

The group emphasized beginning treatment discussions by determining the patient's priorities and comfort with available therapies.

“I would start by asking her what she wants. She already has anxiety, so she may have anxiety about the medications too, and she’s not going to want to be on an oral JAK inhibitor once she starts reading about the side effects and black box warnings,” an attendee said.

Another attendee noted that the location and visibility of hair loss can be as important to an individual patient as the total amount of scalp involvement. A relatively small but highly visible patch, for example, may have a greater psychosocial impact than more extensive hair loss that can be concealed with a hairstyle.

Faleye reviewed patient-reported outcome data for the available JAK inhibitors, illustrating how treatment success can extend beyond changes in SALT scores.

In pooled THRIVE-AA1 and THRIVE-AA2 data, patients receiving deuruxolitinib demonstrated improvements in Hospital Anxiety and Depression Scale measures at week 24 compared with placebo. Observational data presented for ritlecitinib and baricitinib similarly showed improvements in measures of anxiety, depression, and skin-related quality of life during treatment.

“If we’re making patient-reported outcomes better for these patients, I feel like that translates into a lot,” Faleye said.

The discussion then turned to how long clinicians give a JAK inhibitor before determining that treatment has failed. Attendees generally described waiting approximately 6 to 9 months, underscoring the need to establish realistic expectations about the timeline of hair regrowth before treatment begins.

Safety Data and Monitoring Anchor the Advanced Case

The final case involved a 42-year-old man with a 3-year history of AA whose disease had progressed to 85% scalp hair loss, with new involvement of the eyebrows and beard. Previous treatment with a high-potency topical corticosteroid and topical minoxidil for 6 months had resulted in minimal regrowth.

Given the extent and rapid progression of his disease, systemic treatment with a JAK inhibitor was discussed.

The patient underwent CYP2C9 genotype testing and was identified as a normal metabolizer as part of the evaluation for deuruxolitinib treatment. Baseline laboratory evaluation included a complete blood count, hepatitis and tuberculosis screening, and assessment of immunization status.

Attendees said access to CYP2C9 testing had become less of a practical barrier than when deuruxolitinib initially became available, noting manufacturer support for testing.

Monitoring approaches varied among clinicians. Some described relying primarily on baseline testing, whereas others repeated laboratory evaluations at regular intervals during treatment.

One attendee recalled encountering a substantial creatine kinase (CK) elevation in an otherwise asymptomatic patient participating in a clinical trial.

“One thing I’ve run into is elevated CK with some of the patients, especially one where the CK was like 20,000,” the attendee said.

The group also reviewed longer-term safety data for JAK inhibitors. Faleye presented 3-year findings for ritlecitinib and baricitinib, including low reported rates of major adverse cardiovascular events, venous thromboembolism, and malignancy in the data presented during the program.

Thromboembolic History Complicates JAK Inhibitor Selection

The case was then complicated by the addition of a history of 2 deep vein thromboses and a pulmonary embolism. Faced with the patient's thromboembolic history, most attendees said they would avoid initiating a JAK inhibitor or seek input from another specialist before proceeding.

“If there’s some other drug that has less of a side effect profile that works, a JAK is always going to be the last resort for me,” an attendee said.

The conversation also addressed counseling for patients of childbearing age and the practical considerations surrounding JAK inhibitor use when pregnancy is being considered. Attendees discussed how treatment planning should account for an individual's reproductive goals alongside the pharmacologic characteristics and prescribing guidance of the selected therapy.

Faleye closed the discussion by reflecting on how AA management has evolved as effective systemic therapies have become available. Whereas clinicians previously faced substantial uncertainty about what they could offer patients with extensive or progressive disease, multiple approved options now allow treatment to be tailored more closely to the individual.

Across the 3 cases, attendees emphasized that treatment decisions cannot be based on scalp hair loss alone. Disease progression, facial involvement, psychosocial burden, patient goals, treatment timelines, comorbidities, safety considerations, and willingness to accept therapy all play a role in determining the appropriate approach.

Faleye encouraged clinicians to continue evaluating each patient individually rather than defaulting to a uniform treatment strategy for AA.

References

1. Faleye T. Alopecia areata in practice: individualizing care through patient cases. Presented at: Dermatology Times Case-Based Roundtable; September 28, 2026; Houston, TX.
2. King B, Ohyama M, Kwon O, et al. Two phase 3 trials of baricitinib for alopecia areata. N Engl J Med. 2022;386(18):1687-1699. doi:10.1056/NEJMoa2110343
3. King B, Zhang X, Harcha WG, et al. Efficacy and safety of ritlecitinib in adults and adolescents with alopecia areata: a randomised, double-blind, multicentre, phase 2b-3 trial. Lancet. 2023;401(10387):1518-1529. doi:10.1016/S0140-6736(23)00222-2