A 29-year-old woman presents with patchy alopecia areata affecting approximately 21% of her scalp. She has been treated with topical corticosteroids but returns 3 months later with progression to approximately 36% scalp involvement.

She reports increasing anxiety about the hair loss and has begun avoiding social events. Although her SALT score remains below 50—the threshold used for enrollment in pivotal JAK inhibitor trials—her disease is visibly progressing and substantially affecting her quality of life. This mirrors the clinical dilemma discussed during Benjamin Ungar, MD’s roundtable, where clinicians agreed that patients below SALT 50 may still warrant systemic therapy.

Systemic therapy with a JAK inhibitor is initiated based on the patient’s progressive disease and overall clinical burden. At follow-up, scalp hair loss has stabilized, but substantial regrowth has not yet occurred.

The patient questions whether the treatment is working and whether another therapy should be considered. However, response timing in alopecia areata can vary, and clinicians may differ in how long they wait before determining that a treatment has failed.

The patient’s limited early response raises another question: How long should JAK inhibitor therapy be continued before determining that the response is inadequate?

Although the patient’s alopecia areata remained below a SALT score of 50, continued progression and the overall burden of disease supported escalation beyond topical therapy. Systemic treatment with a JAK inhibitor was initiated rather than waiting for the patient to reach a predefined threshold of scalp hair loss.

At follow-up, hair loss stabilized before substantial regrowth became apparent. Rather than interpreting the limited early regrowth as treatment failure, therapy was continued, recognizing that meaningful improvement in alopecia areata may take several months and can vary according to baseline disease severity and treatment trajectory.

The case illustrates how management decisions in alopecia areata extend beyond SALT score alone. Disease progression, patient burden, treatment trajectory, and sufficient time to assess response can all help guide decisions about when to initiate, continue, or reconsider systemic therapy.