Tofacitinib for the Treatment of Severe Alopecia Areata and Variants: A Study of 90 Patients Liu LY, Craiglow BG, Dai F, King BA J Am Acad Dermatol. 2017;76:22-28 Alopecia, in all its various forms, has been extremely frustrating to patients and physicians alike, who have had too few options for treatment. It is a condition that often causes significant stress because of its cosmetic manifestation, so finding an effective treatment has been a long time coming. This recent study is promising, but should physicians start prescribing full steam ahead? What are the alternatives, and what's on the horizon for future treatments? Let's take a look. Background Alopecia areata (AA) and its more severe variants—alopecia totalis (AT) and alopecia universalis (AU)—are autoimmune disorders[1] characterized by variable degrees of hair loss, discrete or diffuse patches of nonscarring hair loss, and perifollicular lymphocytic infiltrates with tapered and broken hair shafts on histopathology. The disease presents in both children and adults, with a worse prognosis seen with early-onset, extensive alopecia (AT or AU) or an ophiasis (band-like, temporal and occipital) pattern. AA is not a rare disease, with a lifetime incidence of up to 1.7% in the general population and higher rates in individuals with autoimmune or inflammatory diseases, including Hashimoto thyroiditis, vitiligo, atopic dermatitis, and psoriasis. Mild AA typically resolves spontaneously, with intralesional corticosteroid injections and topical minoxidil commonly used to expedite hair regrowth. In contrast, more extensive AA is notoriously challenging to treat: Although some studies have suggested that high-dose, intermittent pulsed corticosteroids may yield temporary hair regrowth, relapse rates are discouragingly high.[2] Janus kinase (JAK) inhibitors, such as ruxolitinib and tofacitinib, suppress cytotoxic T lymphocytes and are indicated for the treatment of rheumatoid arthritis, psoriasis vulgaris, and psoriatic arthritis. JAK inhibition reversed CD8(+)NKG2D(+) T-lymphocyte–mediated AA in a murine model,[3] and the oral JAK 1/3 inhibitor tofacitinib dramatically reversed AA in an index patient being treated for plaque psoriasis.[4] These intriguing observations prompted a 3-month open-label trial of 66 patients with AA, showing promising short-term results.[5] Study Summary Inspired by these encouraging data, Liu and colleagues conducted an open-label, retrospective study of 90 adults (median age, 34.5 years; 55.6% female) with AA (14.4%), AU (83.3%), or AT (2.2%). Of this initial group, 65 trial-eligible patients received monotherapy with tofacitinib 5 mg twice daily for the first 2-3 months of treatment. After this induction phase, 29% of patients received a higher tofacitinib dose (up to 10 mg orally twice daily), and 28% of patients started adjuvant therapy with pulsed prednisone. The primary endpoint was the percentage change in the Severity of Alopecia Tool (SALT) score between the first and last visits. Treatment safety was assessed with laboratory studies, examination, and review of systems. Results 1. After 4-18 months of tofacitinib therapy, 77% of patients achieved a clinical response. 2. 58% of patients achieved at least a 50% improvement in SALT scores, and 20% showed a complete response (full hair regrowth) after a median of 15 months of treatment. 3. Patients with AA (n = 13) were better responders than those with AT or AU (n = 52) (81.9% improvement in SALT scores vs 59.0% improvement, respectively). 4. No serious adverse events or laboratory abnormalities were observed after a mean of 1 year of treatment. The most common adverse events were upper respiratory infections (28.9%), headache (14.4%), and acne (7.8%). Discussion In this small but statistically significant study, the oral JAK 1/3 inhibitor tofacitinib showed impressive efficacy in the treatment of AA, AT, and AU. Of note, this trial excluded patients with AA, AU, or AT of greater than 10 years' duration, because prior studies had showed poor tofacitinib efficacy in this group with chronic disease. As Liu and colleagues point out, their trial lacked a control group, and roughly 28% of patients went on to receive adjuvant therapy with pulsed corticosteroids during the trial period. They noted a low spontaneous relapse rate of 7.7%; however, the duration of treatment ranged from 4 to 18 months (median, 12 months). Hence, we do not know whether tofacitinib therapy can induce long-term disease remission, or whether the disease process will resume after drug cessation. This study showed tofacitinib efficacy in adult patients, but oral JAK 1/3 inhibitors also shows promise in adolescents with AA, AU, and AT. A small study (13 patients) showed a median change in SALT score of 93% after a mean of 6.5 months of tofacitinib therapy,[6] and topical JAK inhibitors can induce significant hair regrowth in localized AA.[7] Viewpoint Although tofacitinib therapy was not associated with significant adverse events in this study group, oral JAK inhibitors used to treat rheumatoid arthritis have been associated with significant adverse events, including rare cancers (soft tissue and lymphoma) and serious infections. Whether these risks are unique to patients with rheumatoid arthritis because of comorbidities and concurrent medications, remains to be determined. This is something that many clinicians may not want to gloss over. Some might find it prudent to discuss risks and benefits with patients so that they can make a truly informed decision. JAK 1/3 inhibitors, such as tofacitinib, are a promising new treatment for AA, AU, and AT. Although response rates were not as dramatic for AU and AT, the efficacy in these more severe forms of autoimmune alopecia is especially impressive, given the lack of therapeutic alternatives. Future studies should adopt a randomized, prospective, placebo-controlled design and include long-term follow-up, both with and without maintenance tofacitinib therapy. According to the National Alopecia Areata Foundation, clinical studies of topical treatments, psychological interventions, and additional JAK inhibitor strategies are under way. Until then, we watch and wait. References Islam N, Leung PS, Huntley AC, Gershwin ME. The autoimmune basis of alopecia areata: a comprehensive review. Autoimmun Rev 2015;14:81-89. Smith A, Trueb RM, Theiler M, et al. High relapse rates despite early intervention with intravenous methylprednisolone pulse therapy for severe childhood alopecia areata. Pediatr Dermatol. 2015;32:481-487. Abstract Xing L, Dai Z, Jabbari A, et al. Alopecia areata is driven by cytotoxic T lymphocytes and is reversed by JAK inhibition. Nat Med. 2014;20:1043-1049. Abstract Craiglow BG, King BA. Killing two birds with one stone: oral tofacitinib reverses alopecia universalis in a patient with plaque psoriasis. J Invest Dermatol. 2014;134:2988-2990. Abstract Crispin M, Ko J, Craiglow BG, et al. Safety and efficacy of the JAK inhibitor tofacitinib citrate in patients with alopecia areata. JCI Insight. 2016;1:e89776. Craiglow BG, Liu LY, King BA. Tofacitinib for the treatment of alopecia areata and variants in adolescents. J Am Acad Dermatol. 2017;76:29-32. Abstract Craiglow BG, Tavares D, King BA. Topical ruxolitinib for the treatment of alopecia areata. JAMA Dermatol. 2016;152:490-491. 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