Severity, Response Timing, and Lab Monitoring in Alopecia Areata Care

Benjamin Ungar, MD, dermatologist, director of the Alopecia Center of Excellence, and director of the Rosacea & Seborrheic Dermatitis Clinic at the Kimberly and Eric J. Waldman Department of Dermatology at Mount Sinai, recently led a Dermatology Times Case-Based Roundtable in New York City, New York, guiding 10 dermatology clinicians through the management of alopecia areata (AA). The event reviewed 3 patient cases covering systemic therapy selection, response assessment, and laboratory monitoring.

Defining Severity and Selecting a JAK Inhibitor for Time-Sensitive Regrowth

The first case involved a 33-year-old man with 45% scalp hair loss, minimal response to 4 months of topical corticosteroid, and a wedding in 6 months. All attendees who spoke supported starting an oral JAK inhibitor despite a moderate Severity of Alopecia Tool (SALT) score.

Ungar said the Alopecia Areata Scale (AASc) raises severity based on progression, psychosocial impact, and eyebrow or eyelash involvement. Attendees added flare frequency, coexisting autoimmune disease, and occupational visibility. “I always feel like eyelashes and eyebrows deserve systemic, no matter what,” an attendee said.

In an opening poll of 10 attendees, 60% named extent of scalp involvement as the leading trigger for systemic escalation, and no one selected facial hair, eyebrow, or eyelash involvement. Speed of response was moderately influential for 50% and extremely influential for 40%.

Attendees split on speed versus safety. One favored a safer agent over a faster one, while another viewed all approved JAK inhibitors as equally safe. Others said coverage largely decided the choice.

Ungar reviewed phase 3 data for deuruxolitinib (Leqselvi; Sun Pharma), ritlecitinib (Litfulo; Pfizer), and baricitinib (Olumiant; Eli Lilly), noting a significant deuruxolitinib response at 8 weeks. Attendees said nearly all patients receive baricitinib 4 mg, a preference reinforced by BRAVE-AA1 (NCT03570749) and BRAVE-AA2 (NCT03899259).¹ “Four milligrams is clearly much, much more effective,” Ungar said.

Patient hesitancy surfaced after boxed warning counseling, with one attendee estimating about 60% of patients decline, often citing blood clots. Others framed therapy as indefinite, likening it to thyroid disease or diabetes.

Treatment Success and Response Timing in Progressive Patchy Hair Loss

The second case featured a 29-year-old woman whose scalp hair loss progressed from 21% to 36% in 3 months, with anxiety and social avoidance. She would not have met the SALT 50 or greater eligibility criteria of the pivotal trials, Ungar said.

“I think it’s unfortunate that the threshold was so high because that’s not capturing some patients who I think we all agree are severe,” Ungar said. No attendee said they would withhold a systemic option if she wanted one.

Efficacy led JAK inhibitor selection criteria at 39% of poll selections, followed by safety at 26% and coverage at 17%. After inadequate response, 50% would switch JAK inhibitors, 30% would add adjunctive therapy, and 20% would continue and reassess.

Attendees defined success as halted progression and patient perception rather than SALT 20 or less. “I think with hair growth, patient perception is so important,” an attendee said.

Timelines for declaring nonresponse ranged from 12 weeks to at least 6 to 9 months. Ungar said speed depends on baseline severity, and patients with alopecia universalis may need longer. He adds oral minoxidil for nearly all patients.

Laboratory Monitoring and CYP2C9 Testing in Severe Disease

The third case involved a 42-year-old man with 85% scalp involvement, new eyebrow and beard loss, and a normal-metabolizer CYP2C9 genotype. Attendees classified him as severe without disagreement.

Monitoring practices varied. Attendees checked a complete blood count (CBC) and metabolic panel at 1 and 3 months, or at 3 months only. Ungar orders a CBC, metabolic panel, and lipids at 3 months and 1 year, and recalled perhaps 1 patient whose results altered treatment.

“We’re not checking labs because we think something is going to go wrong. We check them so that we know that it’s staying the same,” an attendee said.

On CYP2C9, 40% said testing only rules patients in or out for deuruxolitinib, 30% do not order it, 20% said it does not inform management, and 10% found value beyond eligibility. Some attendees order it for label adherence or medicolegal protection. Ungar orders it but said it was not checked in the trials.

“There’s no evidence that has any impact on clinical outcomes,” Ungar said.

First follow-up ranged from 1 to 3 months. “The sooner the follow up, the better the compliance,” an attendee said.

In a closing poll, 50% said they already felt comfortable using JAK inhibitors, while 36% requested monitoring best practices and 14% wanted sequencing or switching algorithms. “I think because everything takes so long, the expectation setting is probably 80% of the success of treating alopecia areata,” Ungar said.

Reference

1. 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