What are the recent advances in the treatment of Alopecia areata?

Recent Advances in the Treatment of Alopecia Areata

JAK inhibitors, particularly baricitinib and ritlecitinib, represent the most significant recent advancement in alopecia areata treatment, with baricitinib demonstrating high-certainty evidence of increased short-term and long-term hair regrowth compared to placebo. 1, 2

Current Treatment Algorithm

First-line Treatments

• Limited Patchy Hair Loss (<1 year duration)

  • Consider "no treatment" option due to high spontaneous remission rates (up to 80%) 3
  • Intralesional corticosteroid injections (e.g., triamcinolone acetonide) are first-line with ~62% success rate 3
    • Side effects: Skin atrophy at injection sites, pain during injection

• Extensive Patchy Hair Loss

  • Contact immunotherapy (diphenylcyclopropenone) with 50-60% response rate 3
    • Side effects: Lymphadenopathy, severe dermatitis, pigmentary complications
    • Treatment should continue for at least 6 months before determining efficacy

Alternative Topical Options

• Topical corticosteroids when intralesional steroids aren't tolerated 3

  • Clobetasol propionate 0.05% foam shows promising results with 47% of patients achieving >25% hair regrowth 4
  • Well-tolerated with good patient compliance due to easy application

• Topical minoxidil 5% solution 3

  • Results typically take 3-6 months
  • Effects may last up to 48 weeks
  • Side effect: Scalp irritation

Recent Advances in Systemic Therapy

JAK Inhibitors

• Baricitinib (JAK 1/2 inhibitor) - EMA-approved for adults with severe alopecia areata 1

  • High-certainty evidence shows 7.5 times higher likelihood of achieving ≥75% hair regrowth compared to placebo 2
  • Long-term efficacy also demonstrated with 8.5 times higher likelihood of sustained regrowth 2

• Ritlecitinib (JAK 3/TEC inhibitor) - EMA-approved for individuals aged 12 and older with severe alopecia areata 1

Other Systemic Options (Off-label)

• Oral glucocorticosteroids
• Cyclosporine
• Methotrexate
• Azathioprine
• Oral minoxidil (adjuvant therapy with limited data) 1

Patient Selection for Systemic Therapy

• SALT score ≥20 or moderate-to-severe alopecia on the Alopecia Areata Scale (AAS) constitutes indication for systemic therapy 1
• Consider psychological impact and quality of life impairment 3
• Special consideration for children who may have limited treatment options due to poor tolerance of intralesional corticosteroids 3

Practical Considerations

Monitoring and Follow-up

• Regular follow-up visits to assess treatment response
• Photography to document changes
• Quality of life measures 3

Supportive Care

• Wigs or hairpieces for extensive hair loss
  • Acrylic: cheaper, easier to maintain
  • Human hair: better fit for wider range of activities 3
• Psychological support and referral to patient support groups 3

Caveats and Pitfalls

• Treatment efficacy varies widely among individuals
• Recurrence is common after treatment cessation, particularly with topical treatments 5
• Children and adolescents with alopecia areata often experience bullying and require special attention to psychological support 1
• Many treatments show inconclusive results for hair regrowth despite widespread use 2
• Balance potential benefits against side effects, particularly for newer systemic treatments

The field of alopecia areata treatment has evolved significantly with the approval of JAK inhibitors, offering new hope for patients with severe disease who previously had limited effective options.