INTRODUCTION
Alopecia areata (AA) is a chronic autoimmune disease involving the hair follicle with a high relapse rate and variable response to traditional therapies that nonspecifically target the immune system. Janus kinase (JAK) inhibitors are targeted immunosuppressants shown to improve hair loss in alopecia areata and are available in oral and topical formulations.1-10 Patients with more severe and longstanding disease have shown poorer response to tofacitinib, a JAK 1/3 inhibitor, therapy.9,10 We present a case series of eleven patients with alopecia areata universalis or totalis treated with standard to high dose oral tofacitinib and four patients treated with a compounded topical tofacitinib cream.
METHODS
Eleven patients diagnosed with AA universalis or totalis treated with oral tofacitinib were identified (Table 1). Oral tofacitinib treatment was started at 5 mg once daily, 5 mg twice daily, or 11 mg extended release once daily. Dosage was titrated based on response, tolerability, and insurance coverage. Adjuvant intralesional Kenalog (ILK) was administered at the physician’s discretion. Additionally, we identified four patients with severe AA who were treated with 2% tofacitinib cream twice daily. Notably, two of these patients were treated with oral tofacitinib either prior to or after topical tofacitinib, but not concurrently with topical tofacitinib (Table 2). This case series was approved by the University of California, Los Angeles Institutional Review Board. The review spanned April 1, 2015 to August 20, 2017.Treatment response was evaluated by patient reported time to initial response (defined as time to first documented sign of any hair regrowth) and the validated Severity of Alopecia Tool (SALT) score, with a higher score indicating more severe disease. The SALT score was calculated prior to initiation of treatment and throughout follow-up by a combination of in office physician evaluation and retrospective photographic evaluation. The % SALT score change from baseline was calculated as (initial SALT score - best SALT score on treatment)/initial SALT score x 100%.
RESULTS
Oral TofacitinibPatient characteristics are summarized in Table 1. We identified 10 patients with alopecia areata universalis and one patient with alopecia areata totalis with mean duration of disease of 5.23 years (range, 3-11 years). Patients were treated with oral tofacitinib (range 5 mg once daily to 11 mg extended release twice daily) for a mean treatment duration of 14.4 months (range, 4.5-27 months).The mean time to first response was 1.36 months (range 4 days to 3 months). The mean SALT score improvement from baseline was calculated to be 61.18% (n=10, range, 0%-100%). One patient was not included because she was lost to follow up. Of the ten patients with documented follow-up SALT scores, five patients achieved complete disease resolution (SALT score <=5%), three of whom were treated with adjuvant ILK treatment (5-10 mg/ml) to recalcitrant patches.Five patients temporarily ceased treatment and were observed to have gradual patchy loss of hair regrowth. One patient developed hyperlipidemia and weight gain while on 11 mg extended release twice daily, which improved with exercise and diet changes while remaining on treatment. Other side effects included gastrointestinal symptoms and mild acne. One patient stopped treatment due to new-onset multiple sclerosis.Topical TofacitinibPatient characteristics are summarized in Table 2. We identified 4 patients (3 men, 1 woman) diagnosed with AAU with
