INTRODUCTION
Alopecia universalis is a type of alopecia areata (AA) characterized by total body hair loss. The mechanism of this loss is primarily due to autoimmune disruption of the hair follicle. AA has historically been treated with corticosteroids, minoxidil, and other immune therapies that possess limited efficacy with high recurrence rates and adverse effects.1 However, in recent years the Janus Kinase inhibitors (JAKis) have emerged with novel immunomodulatory effects by blocking interferon-gamma and interleukin-15, involved in immune activation at the hair follicle.2 Currently, three oral JAKis, baricitinib, ritlecitinib, and deuruxolitinib, have been studied under phase 3, randomized, controlled trials for AA.2-5
CASE REPORT/CASE PRESENTATION
We present the case of a 28-year-old female with Alopecia Universalis who experienced rapid onset improvement in hair growth over a 6-month period after 18 total months of JAKi therapy. The patient initially presented to our institution's dermatology clinic with abrupt onset loss of scalp hair with progression of total body hair loss within a few months. At that time, her exam showed scattered terminal hairs on the scalp with few vellus hairs as well as nail pits on multiple nails. The patient's past medical history was significant for Turner's syndrome, hypothyroidism, atopic dermatitis, and an isolated episode of unspecified alopecia at age 11. Her mother reportedly also has a history of alopecia areata. The patient was initially started on an oral prednisone taper, topical corticosteroids, and minoxidil titrated up to 3.75mg with poor response. After 3 months with little to no improvement, baricitinib was added at 2mg and was promptly titrated to 4mg.
Over the next 6 months, the patient noted no regrowth of hair on any body surface area and down-titrated baricitinib to 2mg due to difficulty tolerating the higher dose and minoxidil to 2.5mg, due to weight gain. After one full year on baricitinib, the patient's Severity of Alopecia Tool (SALT) remained at 100%, but she did note improvement in her nail pitting. Her therapy was switched to ritlecitinib at 50mg adjunct with 1.25mg minoxidil, and at 6-month follow up, she began to notice some regrowth of eyelashes and eyebrows as well as the return of fine, vellus hair on the scalp, as seen in Figure 1. With the promising return of vellus hair, the same regimen was continued and after approximately one year of ritlecitinib and two total years of JAKi therapy, she had remarkable improvement in regrowth of terminal hairs on the vertex scalp, eyelashes, and eyebrows, as seen in Figure 2, with a SALT score of 17.2. The patient did
Over the next 6 months, the patient noted no regrowth of hair on any body surface area and down-titrated baricitinib to 2mg due to difficulty tolerating the higher dose and minoxidil to 2.5mg, due to weight gain. After one full year on baricitinib, the patient's Severity of Alopecia Tool (SALT) remained at 100%, but she did note improvement in her nail pitting. Her therapy was switched to ritlecitinib at 50mg adjunct with 1.25mg minoxidil, and at 6-month follow up, she began to notice some regrowth of eyelashes and eyebrows as well as the return of fine, vellus hair on the scalp, as seen in Figure 1. With the promising return of vellus hair, the same regimen was continued and after approximately one year of ritlecitinib and two total years of JAKi therapy, she had remarkable improvement in regrowth of terminal hairs on the vertex scalp, eyelashes, and eyebrows, as seen in Figure 2, with a SALT score of 17.2. The patient did
