What are the immune therapy options for someone with autoimmune alopecia and psoriatic arthritis?

Immune Therapy Options for Autoimmune Alopecia and Psoriatic Arthritis

Primary Recommendation

For a patient with both alopecia areata and psoriatic arthritis, initiate TNF inhibitor therapy (adalimumab, infliximab, or etanercept) to treat the psoriatic arthritis, while recognizing that TNF inhibitors may paradoxically worsen or trigger alopecia areata. 1, 2

Treatment Algorithm for Psoriatic Arthritis

First-Line Treatment (Treatment-Naive Patients)

• TNF inhibitors are conditionally recommended over oral small molecules (OSMs) as first-line therapy for active psoriatic arthritis 1

  • Preferred agents: adalimumab, infliximab, or etanercept 3, 4
  • TNF inhibitors address both joint and skin manifestations effectively 5, 6

• Alternative first-line options if TNF inhibitors are contraindicated or patient preference:

  • Oral small molecules (methotrexate, sulfasalazine, leflunomide) for patients without severe disease who prefer oral therapy 1
  • IL-17 inhibitors (secukinumab, ixekizumab) for patients with severe psoriasis 1
  • IL-12/23 inhibitors (ustekinumab) for patients desiring less frequent administration 1

Second-Line Treatment (Failed OSM Therapy)

• Switch to TNF inhibitor over IL-17 inhibitor, IL-12/23 inhibitor, abatacept, or tofacitinib 1
• IL-17 inhibitors are preferred over IL-12/23 inhibitors if TNF inhibitors are contraindicated 1
• IL-12/23 inhibitors are preferred over abatacept or tofacitinib 1

Third-Line Treatment (Failed TNF Inhibitor)

• Switch to IL-17 inhibitor over IL-12/23 inhibitor, different TNF inhibitor, abatacept, or tofacitinib 1
• Consider switching to different TNF inhibitor if secondary efficacy failure occurred 1

Critical Caveat: Alopecia Areata and TNF Inhibitors

The Paradox

TNF inhibitors, despite being theoretically beneficial for alopecia areata based on TNF-α's role in pathogenesis, have been paradoxically associated with new-onset or worsening alopecia areata. 2, 7

• Adalimumab has been reported to trigger new-onset alopecia areata in patients treated for psoriatic arthritis 2
• Alopecia universalis (complete body hair loss) with onychodystrophy has occurred 3 months after adalimumab initiation 7
• This paradox suggests TNF-α may not be the primary driver of alopecia areata pathogenesis, and other inflammatory pathways must be involved 2, 7

Clinical Decision-Making

Prioritize treating the psoriatic arthritis with TNF inhibitors, as:

• Psoriatic arthritis causes progressive joint destruction and functional impairment affecting morbidity and quality of life 3
• Alopecia areata, while psychologically distressing, does not cause physical morbidity or mortality 2
• TNF inhibitors remain the most effective first-line biologic therapy for psoriatic arthritis 1, 3

Monitor closely for:

• New hair loss or worsening alopecia after TNF inhibitor initiation 2, 7
• Development of alopecia universalis or nail changes 7
• If significant worsening occurs, consider switching to IL-17 or IL-12/23 inhibitors 1

Alternative Biologic Options if TNF Inhibitors Worsen Alopecia

IL-17 Inhibitors

• Secukinumab or ixekizumab are effective for psoriatic arthritis and severe psoriasis 1
• Preferred over IL-12/23 inhibitors for psoriatic arthritis efficacy 1
• No established association with alopecia areata in literature

IL-12/23 Inhibitors

• Ustekinumab is effective for psoriatic arthritis with less frequent dosing (every 12 weeks) 1
• Preferred if concomitant inflammatory bowel disease exists 1
• No established association with alopecia areata in literature

JAK Inhibitors

• Tofacitinib is an oral option for psoriatic arthritis 1
• Lower in treatment hierarchy compared to TNF and IL-17 inhibitors 1
• Theoretically may benefit alopecia areata through different mechanism, though not FDA-approved for this indication

Combination Therapy Considerations

• Biologic monotherapy is preferred over biologic plus methotrexate combination for most patients 1
• Consider adding methotrexate to biologic if:
  • Severe skin manifestations present 1
  • Partial response to current methotrexate therapy 1
  • Concomitant uveitis (methotrexate may benefit uveitis) 1
  • Using infliximab or adalimumab specifically 1

Special Populations

Patients with Recurrent Infections

• Avoid TNF inhibitors (black box warning for serious infections) 1
• Use IL-12/23 or IL-17 inhibitors instead 1
• Abatacept may be considered for patients with recurrent serious infections 1

Patients with Inflammatory Bowel Disease

• Use monoclonal antibody TNF inhibitors (infliximab, adalimumab) over etanercept (strong recommendation) 1
• Avoid IL-17 inhibitors (not effective for IBD, may worsen) 1
• IL-12/23 inhibitors are acceptable alternative 1

Monitoring and Adjustment

• Assess disease activity regularly and adjust therapy if inadequate response 3
• Target remission or low disease activity for psoriatic arthritis 3
• Document hair loss progression with photography if alopecia worsens on TNF inhibitor 2
• Switch biologic class if alopecia universalis develops or quality of life significantly impacted 7