Treatment Of Severe Alopecia Areata Research Articles

52874 Timing of eyebrow and eyelash regrowth among subgroups of scalp responders during treatment of severe alopecia areata with baricitinib

52874 Timing of eyebrow and eyelash regrowth among subgroups of scalp responders during treatment of severe alopecia areata with baricitinib

JAAD Game Changers: “Tofacitinib for the treatment of severe alopecia areata and variants: A study of 90 patients”

JAAD Game Changers: “Tofacitinib for the treatment of severe alopecia areata and variants: A study of 90 patients”

Update on pulse corticosteroid therapy for the management of alopecia areata

AbstractAlopecia areata is a nonlife‐threatening autoimmune disorder and often requires systemic treatment to stop the disease from progressing. Pulse corticosteroid therapy (PCT) is a common way to treat severe alopecia areata although the exact benefit on this treatment remains unclear. The aim of this article is to update current knowledge of hair regrowth rates after PCT. Twenty studies with a total of 2144 patients were reviewed. Eight out of 20 studies allow statements on patients who did not respond at all on PCT. From 680 patients in those eight studies, 211 showed no response, which equals a rate of 31.02%. However, nine out of the 20 studies point out how many patients achieved hair regrowth >50% or a reduction in Severity of Alopecia Areata Tool Score by >50%: 131 patients out of 272 achieved a response with >50% hair regrowth, which corresponds to a rate of 48.16%. Complete regrowth of hair was observed and documented in nine studies: Out of the 1757 patients, 677 showed full regrowth leading to a complete response rate of 38.53%. At University Hospital Bonn, Department of Dermatology, Germany, PCT has been an established treatment for severe alopecia areata over the past decades. Nevertheless, many unwanted side effects were observed. A retrospective study on hair regrowth after PCT was performed in 2022 and is also part of this article. Nineteen studies from literature search through the PubMed database and the one own study led to a total of 20 studies being reviewed in this article.

Treatment of moderate-to-severe alopecia areata in patients over the age of 65 years with baricitinib.

Baricitinib is a Janus kinase inhibitor that has been approved by the US Food and Drugs Administration for the treatment of severe alopecia areata (AA) in adults. However, the clinical trials that demonstrated the efficacy of baricitinib in the treatment of severe AA did not include men aged > 60 years or women aged > 70 years. We retrospectively assessed the efficacy and safety of baricitinib in 14 patients aged ≥ 65 years with moderate-to-severe AA. After a mean (SD) duration of 18.5 (11.9) months, a 72% reduction in mean Severity of Alopecia Tool score from baseline was observed. Partial or complete eyebrow and eyelash hair was observed in 57% and 43% of patients, respectively. The adverse effects of baricitinib were mild. No cases of venous thromboembolism, major adverse cardiovascular events or malignancy were reported.

Factors Affecting the Response and Patient Satisfaction of Topical Immunotherapy in Alopecia Areata: A Nationwide Study.

Contact immunotherapy using diphenylcyclopropenone (DPCP) is a recommended treatment for severe alopecia areata (AA); however, few clinical factors are known, and few standardized application methods affecting therapeutic efficacy have been devised. To confirm the therapeutic response of DPCP immunotherapy in AA, first we analyze the factors influencing its outcome and patient satisfaction levels, after which we standardize the DPCP treatment method for better outcomes. We utilized a nationwide questionnaire-based survey to assess patient satisfaction and undertook a medical record review involving 412 patients currently undergoing treatment for DPCP. The patients' mean age was 36.4 years, and 27% of the cases were diagnosed as AA in childhood. Treatment response was higher when DPCP was used to treat the entire scalp, including subclinical lesions, and longer treatment durations and longer intervals between treatments were associated with a better treatment response. Atopy (atopic dermatitis, allergic rhinitis and bronchial asthma), thyroid disorder, and extent of hair loss were all negatively correlated with the treatment response. However, there was no correlation between the treatment response and factors such as the age of onset, a family history of AA, nail changes, or AA duration, which are commonly known to be associated with a poor prognosis. DPCP immunotherapy is an effective treatment for AA, and the study demonstrated the factors affecting DPCP treatment response and patients' satisfaction and may contribute to standardizing the DPCP treatment method for better outcomes.

Effectiveness and Predictive Factors of Response to Tofacitinib Therapy in 125 Patients with Alopecia Areata: A Single-centre Real-world Retrospective Study.

Alopecia areata is an autoimmune disorder that greatly impacts patients' quality of life, and its management remains challenging. Tofacitinib is the first Janus kinase inhibitor to be approved for clinical use and is the most extensively studied. Several studies have demonstrated the clinical effectiveness of oral tofacitinib in treating patients with alopecia areata. However, despite being widely used in clinical practice, no prospective randomized controlled trials have been implemented and its indication criteria have not been thoroughly established. Moreover, little is known about the factors associated with response to therapy under real-world conditions. The aims of this retrospective cohort study of patients with alopecia areata treated with tofacitinib for 3 months were to assess the effectiveness of tofacitinib and to identify predictive factors of response to it. Primary outcome was the change in disease severity, as evaluated by Severity of Alopecia Tool (SALT) grade. A total of 125 patients with alopecia areata were included, the incidence of effectiveness was 83.2%, and 16.0% of patients achieved a result of complete remission. Total duration of alopecia areata and previous hair regrowth were independent predictors of response. Combined therapy was associated with relapse after discontinuation. No severe adverse event was observed. This study suggests that tofacitinib provides an effective treatment option for patients with alopecia areata, and that earlier intervention in the treatment of severe alopecia areata with tofacitinib may lead to better outcomes.

Ritlecitinib (Litfulo) for severe alopecia areata.

The FDA has approved ritlecitinib (Litfulo – Pfizer), an oral JAK and TEC kinase family inhibitor, for treatment of severe alopecia areata in patients ≥12 years old. Ritlecitinib is the second oral drug to be approved in the US for treatment of severe alopecia areata; baricitinib (Olumiant), a JAK inhibitor, is approved only for use in adults.

Real-Life Effectiveness and Tolerance of Baricitinib for the Treatment of Severe Alopecia Areata with 1-Year Follow-Up Data.

The efficacy of conventional treatments for alopecia areata (AA) has been extremely variable and disappointing, with a high rate of relapse. Recent clinical trials and real-life studies have demonstrated efficacy and safety of baricitinib (an oral Janus kinase 1 and 2 inhibitor) in alopecia areata. We retrospectively evaluated the effectiveness and tolerance of baricitinib in alopecia areata in a real-life Belgian monocentric adult cohort. The primary outcome was evaluated by the percentage of patients who achieved a Severity of Alopecia Tool (SALT) score of ≤ 20 at the end of the follow-up. All treatment-emergent adverse events were collected. In this 19-patient series, with a median ± interquartile range (IQR) follow-up duration of 13 ± 16.2months, we demonstrated that: (i) hair regrowth was observed in nearly 90% of patients between 4 and 16weeks after initiation of baricitinib; (ii) at the end of the follow-up, more than 70% and, in particular, 100% of patients with patchy AA, reached the primary outcome (SALT score ≤ 20); (iii) almost half of the patients, mostly with patchy AA, showed a complete hair regrowth (SALT score = 0), within a median ± IQR treatment time of 8.5 ± 10months; (iv) baricitinib was discontinued in three patients with total hair regrowth, two of whom relapsed; and (v) no serious adverse events were reported. Baricitinib is effective in treating patients with alopecia areata, particularly for the patchy phenotype, but with a risk of relapse after discontinuation. Safety data are reassuring, with lipid changes being the most frequent adverse event.

When to expect scalp hair regrowth during treatment of severe alopecia areata with baricitinib: insights from trajectories analyses of patients enrolled in two phase III trials.

Baricitinib is approved for the treatment of adults with severe alopecia areata (AA). In the absence of robust data on the patterns of regrowth during treatment of severe AA, there is a gap in the knowledge regarding treatment expectations. To examine whether different clinical response subgroups could be identified in baricitinib-treated patients with severe AA and factors that contribute to these subgroups. The BRAVE-AA1 and BRAVE-AA2 phase III trials enrolled patients with severe AA [Severity of Alopecia Tool (SALT) score ≥ 50 (≥ 50% scalp hair loss)]. Patients randomized to baricitinib 4 mg or 2 mg retained their treatment allocation for 52 weeks. Based on patterns identified through growth mixture modelling (GMM), patients were categorized into responder subgroups according to when they first achieved ≥ 30% improvement from baseline in SALT score (SALT30). For each responder subgroup, trajectories of response (i.e. achievement of a SALT score ≤ 20, SALT score ≤ 10 and ≥ 50% change from baseline in SALT score) and baseline disease characteristics are reported. Respectively, 515 and 340 patients were randomized to once-daily baricitinib 4 mg and 2 mg at baseline; 69% and 51%, respectively, achieved SALT30 at least once by week 52. Based on GMM findings, we identified three responder subgroups: early (SALT30 by week 12), gradual (SALT30 after week 12-week 36) and late (SALT30 after week 36-week 52). The proportions of early, gradual and late responders and nonresponders were, respectively, 33%, 28%, 8% and 31% among patients treated with baricitinib 4 mg, and 20%, 23%, 9% and 49%, respectively, among those treated with baricitinib 2 mg. Early responders had a shorter trajectory to maximal clinical outcomes (e.g. > 78% achieved a SALT score ≤ 20 by week 36) vs. gradual or late responders. Early responders were more frequent among patients with baseline severe AA (SALT score 50 to < 95) vs. very severe AA (SALT score 95-100). Overall, responders (early to late) were more frequent in patients with short (< 4 years) episodes of hair loss. These analyses identified early, gradual and late responder subgroups for scalp hair regrowth in baricitinib-treated patients with severe AA, and that these subgroups are influenced by baseline characteristics. Findings from these analyses will help to inform treatment expectations for scalp hair regrowth.

43696 Early real-world experience with baricitinib in the treatment of severe alopecia areata

43696 Early real-world experience with baricitinib in the treatment of severe alopecia areata

Ritlecitinib: First Approval.

Ritlecitinib (LITFULO™), an orally administered kinase inhibitor, is being developed by Pfizer for the treatment of alopecia areata, vitiligo, ulcerative colitis and Crohn's disease. On 23 June 2023, ritlecitinib received approval in the USA for the treatment of severe alopecia areata in adults and adolescents 12 years and older. Ritlecitinib was approved in Japan on 26 June 2023 for the treatment of alopecia areata (limited to intractable cases involving widespread hair loss). Ritlecitinib has also received a positive opinion in the EU and is under regulatory review in the UK and China. This article summarizes the milestones in the development of ritlecitinib leading to this first approval for severe alopecia areata.

Baricitinib: A Review in Severe Alopecia Areata.

Baricitinib (Olumiant®), a Janus kinase (JAK) inhibitor, is the first drug approved for the treatment of severe alopecia areata in the USA and the EU. Severe alopecia areata is usually difficult to treat and relapse is common. Patients with this disorder are more likely to suffer from anxiety and depression. In two pivotal placebo-controlled phase 3 clinical trials in adults with severe alopecia areata, oral baricitinib once daily was associated with clinically meaningful scalp, eyebrow, and eyelash hair regrowth over 36 weeks. Baricitinib was generally well tolerated with the most common adverse events being infections, headaches, acne, and elevated levels of creatine phosphokinase. While longer-term data will be necessary to more fully understand the benefits and risks of the drug, currently available data suggest that baricitinib is a useful treatment for patients with severe alopecia areata.

Baricitinib for alopecia areata.

Alopecia areata is a disease in which an active immune response is triggered against the hair follicles, causing hair loss. The extent of this hair loss is proportional to the number of hair follicles attacked. Alopecia areata is classified into three types depending on the area of hair fall: alopecia areata, alopecia totalis, and alopecia universalis. Alopecia areata has an approximate worldwide prevalence of 1 in 1000 people1. The current, well-known treatment of alopecia areata is intralesional corticosteroid injections, with 60-70% of patients reporting some form of hair growth afterward, while other treatments include topical immunotherapy, Minoxidil, and Anthralin2. Similar treatment methods, along with hair transplants and platelet-rich plasma (PRP) therapy, are used in Pakistan, which has been effective to some extent in controlling or stopping the progression of the condition3. Baracitinib, which has already been approved for rheumatoid arthritis and atopic dermatitis, is a Janus kinase (JAK) inhibitor that blocks the proteins known as JAK enzymes, which are involved in immune signalling and inflammation. It is unclear as to how the immune system of the body causes alopecia areata. A possible mechanism is by sending out signals that interrupt the events of hair growth. Baracitinib stops the communication among the immune cells responsible for causing hair loss which ultimately inhibits the signals mentioned above and lessens the response to injury, resulting in hair regrowth4. Thus, it can be thought of as a potential treatment for severe alopecia areata. Recently, in June 2022, FDA approved baricitinib as the first systematic treatment for alopecia areata after two clinical trials were conducted by Brett King et al. The trial showed promising results regarding the use of barticinib as after 36 weeks of exposure, oral baricitinib outperformed placebo in terms of promoting hair growth in patients with severe alopecia areata. The proportion of participants that achieved at least 80% scalp hair coverage at 36 weeks was estimated to be 38.8% with 4-mg baricitinib, 22.8% with 2-mg baricitinib, and 6.2% with placebo in trial 1 and 35.9%, 19.4%, and 3.3%, respectively, in trial 25. ---Continue

Baricitinib as the first systemic treatment for severe alopecia areata

ABSTRACT Introduction Alopecia areata is a heterogenous, immune-mediated hair loss disorder that can affect any hair-bearing site on the body. Despite being one of the most prevalent autoimmune skin diseases, treatments have historically been limited to off-label medications that have demonstrated limited efficacy, especially in more severe forms of disease. Thus, there has long been an unmet need for rigorously studied therapeutics in alopecia areata. Areas covered Janus kinase inhibitors have proven to be an effective class of drugs for treating several inflammatory disorders. One such drug, baricitinib, has recently demonstrated significant hair regrowth in phase 2 and 3 alopecia areata trials. It has since become the first systemic therapy approved for treating severe alopecia areata. This review examines the role of Janus kinase pathways in alopecia areata’s pathogenesis and the safety and efficacy of baricitinib for treating severe alopecia areata. Expert opinion The approval of baricitinib for treating severe alopecia areata marks a major milestone in the disease’s history. While baricitinib has proven to be efficacious for this indication and has demonstrated an overall good safety profile, patients’ individual risk factors for serious adverse events should be assessed during shared decision-making with patients before initiating treatment.

Long-term prognosis of subclinical sensitization with diphenylcyclopropenone in patients with alopecia areata

To the Editor: Contact immunotherapy is widely used in the treatment of severe alopecia areata (AA). 1 Meah N. Wall D. York K. et al. The alopecia areata consensus of experts (ACE) study: results of an international expert opinion on treatments for alopecia areata. J Am Acad Dermatol. 2020; 83: 123-130 Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar However, due to varied treatment response to contact immunotherapy, predicting the prognosis of AA is challenging. 2 Lamb R.C. Young D. Holmes S. Retrospective review of diphencyprone in the treatment of alopecia areata. Clin Exp Dermatol. 2016; 41: 352-358 Crossref Scopus (20) Google Scholar A systematic review of contact immunotherapy reported a recurrence rate of 49% in the absence of maintenance treatment. 3 Lee S. Kim B.J. Lee Y.B. et al. Hair regrowth outcomes of contact immunotherapy for patients with alopecia areata: a systematic review and meta-analysis. JAMA Dermatol. 2018; 154: 1145-1151 Crossref PubMed Scopus (46) Google Scholar However, there were no results for long-term prognosis. The modified diphenylcyclopropenone (DPCP) treatment protocol, characterized by subclinical sensitization, has a therapeutic efficacy as favorable as that of the standard protocol, with fewer side effects. 4 Choe S.J. Lee S. Pi L.Q. et al. Subclinical sensitization with diphenylcyclopropenone is sufficient for the treatment of alopecia areata: retrospective analysis of 159 cases. J Am Acad Dermatol. 2018; 78: 515-521.e4 Abstract Full Text Full Text PDF Scopus (10) Google Scholar In a previous study conducted at our institution in 2017, 46 of 159 patients who underwent the modified DPCP treatment protocol showed complete response (CR). After a 2-year follow-up of patients who achieved CR during that time, 20 experienced recurrence. 4 Choe S.J. Lee S. Pi L.Q. et al. Subclinical sensitization with diphenylcyclopropenone is sufficient for the treatment of alopecia areata: retrospective analysis of 159 cases. J Am Acad Dermatol. 2018; 78: 515-521.e4 Abstract Full Text Full Text PDF Scopus (10) Google Scholar The purpose of this study was to examine the long-term prognosis and related factors by confirming the recurrence of AA in the remaining 26 patients with CR.

Intramuscular Corticosteroid Therapy in the Treatment of Alopecia Areata: A Time-to-Event Analysis.

IntroductionIntramuscular corticosteroids (IMC) have gained popularity for the treatment of severe alopecia areata (AA) in recent years; however, evidence on their efficacy and safety is still limited.ObjectiveTo evaluate the efficacy, relapse rate, and tolerability of IMC in the treatment of AA, as well as factors associated with treatment outcomes.MethodsTime-to-event analysis was performed on patients with severe, extensive, or rapidly progressive AA receiving IMC. The IMC regimen comprised triamcinolone acetonide 20–40 mg/mL injected every 4–6 weeks. The evaluated outcomes included initial (25% regrowth), significant (75% regrowth), and complete hair regrowth (100% regrowth). Relapse and adverse events were also noted. Factors associated with treatment outcomes and relapse were analyzed using the Cox proportional hazards model.ResultsA total of 101 patients were eligible for analysis. Significant hair regrowth was obtained in 80.2% of the patients (n = 81), in a median time of 3.4 months (95% confidence interval [CI] = 2.9–4.4). Complete hair regrowth was achieved in 48.5% of the subjects (n = 49), and relapse was observed in 47.5% (n = 48). Acneiform eruption was the most common adverse effect. Multivariable analysis revealed that nail involvement was a negative predictor of significant hair regrowth (adjusted hazard ratio [HR] = 0.04, 95% CI = 0.01–0.55; P = 0.015), whereas duration of AA longer than 6 months was associated with disease recurrence (adjusted HR = 4.02, 95% CI = 1.52–4.66; P = 0.005).ConclusionThis study demonstrated the efficacy and safety of IMC in the treatment of severe or active AA; however, the relapse rate remained relatively high after discontinuation of the therapy. Nail involvement was a negative predictor of significant hair regrowth, while disease duration longer than 6 months predicted AA relapse.

Dermatology - Latest developments in targeted therapies for atopic dermatitis, alopecia areata and chronic spontaneous urticaria

In recent years, a lot of targeted therapies have appeared on the market. The huge choice and rapid development make it sometimes difficult to stay up to date. This article reviews the latest therapies in the field of atopic dermatitis, alopecia areata and chronic spontaneous urticaria. Anti-IL-4 and anti-IL-13 antibodies and, more recently, JAK inhibitors have been proven to be effective for moderate to severe atopic dermatitis. JAK inhibitors seem promising for the treatment of severe alopecia areata. Ligelizumab and nemoli zumab will provide therapeutical options for chronic spontaneous urticaria and prurigo respectively. These breakthroughs will improve the quality of life of people suffering from invalidating dermatitis, at a certain price.

Comparative study between the efficacies of azathioprine and mesalazine in the treatment of severe alopecia areata.

Various systemic agents have been assessed for treatment of alopecia areata; however, there is a paucity of comparative studies. To compare the efficacy of azathioprine versus mesalazine in the treatment of severe alopecia areata. Our study was carried out in 30 patients with severe alopecia areata divided into two groups, group A: fifteen patients were treated by azathioprine in an oral dose of 1-2mg/kg/day and group B: fifteen patients were treated by mesalazine in an oral dose of 15-30mg/kg/day in two divided doses. The treatment was considered effective if percentage regrowth of hair was determined by change in SALT score >50 from base line after 6months of treatment. The treatment was continued for 3-6months after complete remission to minimize the risk of relapse. The dose was gradually tapered during this time. The study found that there is statistically significant difference between mean SALT scores before treatment and after 6months of treatment in both groups. In group A, SALT score at base line was 84.42±17.41, after 6months it was 35.95±35.79 (p value 0.04). In group B, SALT score at base line was 73.06±22.10, after 6months it was 23.04± 12.27 (p value 0.037). Changes in SALT score after 6months were -27.74±20.66 in group A and -60.42±38.41 in group B (p value 0.055). Mesalazine may be considered as effective as azathioprine with lesser side effects. Azathioprine is also considered safe. However, a large group study should be performed to confirm these findings.

Economic Impact of Home-Use versus Office-Use Diphenylcyclopropenone in Extensive Alopecia Areata

Introduction: Diphenylcyclopropenone (DPCP) is the medication of choice for the treatment of severe alopecia areata (AA) according to AA treatment guidelines. Precise initiation and application are important factors for successful treatment. However, it is difficult for patients who live far away to visit their doctor weekly. Methods: We conducted a retrospective cohort study to assess the cost, effectiveness, and side effects of DPCP treatment between office-use DPCP (O-DPCP) and home-use DPCP (H-DPCP) in severe AA patients. A cost-effectiveness analysis was performed from the perspective of healthcare providers and patients using real-world data and the national cost statistics for hospital services comparing O-DPCP and H-DPCP in patients with severe AA at 24, 36, and 48 weeks. Results: Two groups of 41 patients treated with O-DPCP and H-DPCP were enrolled. There was no significant difference in the proportion of patients who showed a favorable outcome (≥50% improvement) with minimal side effects between both groups at 24 (O-DPCP 43.9% vs. H-DPCP 26.8%, p = 0.11), 36 (O-DPCP 58.5% vs. H-DPCP 43.9%, p = 0.19), or 48 weeks (O-DPCP 63.4% vs. H-DPCP 56.1%, p = 0.49). The cost of H-DPCP was half of the cost of O-DPCP. Discussion/Conclusion: H-DPCP is a cost-effective and time-efficient alternative treatment option for severe AA patients.

Alopecia areata flare patterns in children and young adults while on systemic tofacitinib

To the Editor: The systemic Janus kinase inhibitor tofacitinib is a novel therapeutic that is used off-label for the treatment of alopecia areata (AA) in both children and adults.1Craiglow B.G. King B.A. Tofacitinib for the treatment of alopecia areata in preadolescent children.J Am Acad Dermatol. 2019; 80: 568-570Google Scholar, 2Castelo-Soccio L. Experience with oral tofacitinib in 8 adolescent patients with alopecia universalis.J Am Acad Dermatol. 2017; 76: 754-755Google Scholar, 3Cheng M.W. Kehl A. Worswick S. Goh C. Successful treatment of severe alopecia areata with oral or topical tofacitinib.J Drugs Dermatol. 2018; 17: 800-803Google Scholar Given that systemic tofacitinib is a relatively new treatment option, little is known about its long-term effectiveness. Previous studies have highlighted the possible transient efficacy of oral tofacitinib and the need for dose escalation or adjuvant therapy in periods of AA relapse, but it remains unclear whether there are any consistent flare patterns among patients.4Chiang A. Ortenzio F. Juhasz M.L.W. Yu V. Mesinkovska N.A. Balance of tofacitinib efficacy and disease flare in the treatment of alopecia universalis: A case report and review of the literature.JAAD Case Rep. 2018; 4: 733-736Google Scholar We report the characteristics and flare patterns of 21 pediatric and young adult patients with moderate-to-severe AA while on systemic tofacitinib (Table I). The mean consecutive time on tofacitinib was 31 months (range, 12-58 months). Most patients had severe AA with the absence of the majority of scalp hair and some with loss of body hair at the time of tofacitinib initiation. AA flare was defined as an increase in overall severity of alopecia tool (SALT) score by greater than 10%. Provoked flares occurring after tofacitinib dose de-escalation or brief discontinuation (eg, during acute illness) were excluded.Table IDemographics and flare characteristics of patients with alopecia areata on long-term systemic tofacitinibPatient characteristicsTotalPatients21Mean age at tofacitinib initiation, years (range)15.5 (6-20)Sex Male10 Female11Race/Ethnicity White, non-Hispanic15 Asian3 African American1 White, Hispanic1 Unreported1Mean consecutive time on tofacitinib, months (range)31 (12-58)SALT score at tofacitinib initiation 1-250 26-501 51-753 76-995 10012History of atopy No12 Yes9History of additional autoimmune disease No15 Yes6AA flares on tofacitinib Yes8 No13Mean time to AA flare, months (range)13.6 (10-18)Mean increase in SALT score with AA flare (range)35.95 (11-97)Mean duration of severe AA episode prior to tofacitinib, months (range) Flare11.8 (7-27) No flare15.1 (4-72)Mean age at diagnosis with AA, years (range) Flare10.3 (4-14) No flare9.3 (1-16)AA, Alopecia areata; SALT, severity of alopecia tool. Open table in a new tab AA, Alopecia areata; SALT, severity of alopecia tool. Eight patients (38.1%) had an AA flare while on daily tofacitinib therapy. Prior to the flare, patients had successful hair regrowth on tofacitinib with a mean SALT score decrease of 79.1 from initiation. The mean time to flare was 13.6 months (range, 10-18 months; Fig 1). The mean increase in the SALT score during a flare was 35.9 (range, 11-97). No patient had more than 1 flare while on therapy. When comparing the group of patients who flared while on tofacitinib to those who did not, there was no significant difference in the mean duration of the most recent severe AA episode (11.8 and 15.1 months, respectively; P = .62) or mean age at AA diagnosis (10.3 and 9.3 years, respectively; P = .67). In the setting of acute flares, 6 of 8 patients continued taking initial doses of tofacitinib (10 mg/day) and for 2 of 8 patients, the dosage increased (15 mg/day). Five patients were followed up after flare, and each had SALT scores comparable (within 5 or lower) to preflare values within 1-5 months. During flares, 2 of these patients continued tofacitinib monotherapy but with an increased dose, 2 patients were treated with a combination of oral prednisone (3-week taper starting at 60 mg and decreasing by 20 mg weekly) and intralesional Kenalog, and 1 patient was treated with intralesional Kenalog alone (Supplementary Table I available via Mendeley at https://doi.org/10.17632/7k99v7gvkg.1). Most patients tolerated tofacitinib well but several reported side effects, such as increased frequency of mild infections (4 patients) and gastrointestinal upset (3 patients). Systemic Janus kinase inhibitors are a treatment option for children and young adults with AA; however, we found that a subgroup of patients on long-term systemic tofacitinib therapy experienced AA flares during treatment. It is important for patients and families to understand that even if rapid hair regrowth is achieved initially on promising therapeutics like tofacitinib, flares are possible despite consistent therapy, given the waxing and waning nature and complex pathophysiology of AA. Patients should be informed in advance of potential decreased treatment response to tofacitinib and should be prepared to discuss dosage escalation and/or adjuvant therapy during flares in order to minimize hair loss. None disclosed.