Navigating the Alopecia Areata Treatment Landscape

Highlighting insights from his extensive clinical experience and 2024 Fall Clinical Dermatology Conference for PAs and NPs session “What’s New in Alopecia Areata,” James Song, MD, director of clinical research at Frontier Dermatology Partners in Seattle, Washington, emphasized the importance of early intervention, shedding light on the efficacy and safety profiles of emerging therapies that are approved or in the pipeline.¹

In an interview with Dermatology Times, Song also addressed genetic and immunological nuances, and discussed how tailored treatment approaches can optimize patient outcomes. Moreover, Song spoke to the growing interest in oral minoxidil, elucidating its role as a complementary option in hair loss management.

Dermatology Times: If you could give 1 piece of advice on alopecia areata management, what would it be?

James Song: The key points that I really want to stress is that we have now 2 very good therapies for alopecia areata. We don't have to wait until someone lost all their hair before we consider using these medications. There are reasons that we can start these medications much sooner, so if the patient has really bad anxiety and depression because of the hair loss, or to have it in particular areas that are more visible, like the sides, for example, or the top, or the patient is this rapidly losing hair, we shouldn't wait too long to start these patients on the medication. That's really kind of the main take home point [in this session].

Dermatology Times: What does the current treatment landscape look like for alopecia areata?

Song: We're really fortunate, actually, to have a couple of really good therapies for alopecia areata, 2 of which are currently approved, 1 that should get approved, hopefully within the next year or so. Baricitinib (Olumiant; Eli Lilly and Company)--This is an oral JAK1/2 inhibitor, and it's the first one that was approved for 18 and up and we're seeing continuing good response over time. We actually now have 3 years worth of data. And what we showed is that if you're growing back most of your hair by 1 year, but 90% of these patients still maintain the hair regrowth at that 3 year mark. From a safety standpoint, it still looks very, very good, very low rates of these adverse events of interest. And we're not seeing any new signals coming up over time.²

The second JAK inhibitor is called ritlecitinib (Litfulo; Pfizer), this is a JAK3/TEC inhibitor. So this works a little bit differently than what we saw with baricitinib. This is actually approved for 12 and up now.It's the same inclusion criteria as you had to have 50% or more scalp loss to get into the studies. But very similar, we saw that in about 24 weeks, about a quarter of patients are getting to a meaningful hair growth. And over time through 2 years, these numbers continue to go up. We also saw that there are different treatment trajectories. So, there are different growth patterns, some grow their hair very quickly, some can take longer. And what seemed to be consistent is that the more severe disease you had, and the longer that disease had not been treated for, the less likely you are going to respond or the longer it was going to take for you to actually have a response. Now the nice thing with ritlecitinib is that unlike other JAK inhibitors, you don't actually have to worry about the lipids. So you don't actually have to check lipids at all if you don't want to and it's under US prescribing information.²

Lastly, we talked about deuruxolitinib (Sun Pharmaceutical Industries Inc.). This is not currently approved, but this is an oral JAK1/2 inhibitor as well. Two different doses that were studied, showed some of the most robust efficacy we've seen and some of the fastest responses that we've seen out of any JAK inhibitor. Now there are some safety things that came up with a higher dose of deuruxolitinib. We did see there was a higher rates of blood clots, and so the FDA actually didn't make the patients drop down to the lower dose and so we will need more long-term data really to understand the safety profile of this newer JAK inhibitor.³

Dermatology Times: What genetic or immunological findings influence alopecia areata management?

Song: We do know that alopecia areata could be somewhat of a mixed bag so there are some patients that their alopecia areata is driven primarily by what we call a Th1 response. So JAK inhibitors generally work very well for Th1 diseases, but there are also patients that might have more of a Th2 skewing too. Th2 is what we typically think about for atopic dermatitis, and it turns out that for some of these patients, actually biologics that are approved for atopic dermatitis, like dupilumab (Dupixent; Sanofi and Regeneron) actually could work for alopecia areata in these patients as well.

Dermatology Times: What should clinicians know about oral minoxidil for hair loss?

Song: Oral minoxidil has been kind of the talk of town for alopecia, for the last at least a year or so, and we're using it for all different types of hair loss--androgenetic alopecia and telogen effluvium. We're also using it for alopecia areata. So we actually have some good studies to show you can use oral minoxidil in addition to JAK inhibitors safely and effectively in patients.

Transcript has been edited for clarity.

References

1. Song J. What’s new in alopecia areata. Presented at: 2024 Fall Clinical Dermatology Conference for PAs and NPs; May 31-June 2; Scottsdale, AZ.
2. Wei D, Chen Y, Shen Y, Xie B, Song X. Efficacy and safety of different JAK inhibitors in the treatment of alopecia areata: a network meta-analysis. Front Immunol. 2023;14:1152513. Published 2023 Apr 17. doi:10.3389/fimmu.2023.1152513
3. Chim I, Ghiya R, Sinclair RD, Eisman S. Novel investigational drugs for alopecia areata and future perspectives. Expert OpinInvestig Drugs. Published online May 20, 2024. doi:10.1080/13543784.2024.2348062