Successful Treatment of Severe Alopecia Areata With Oral or Topical Tofacitinib

July 2018 | Volume 17 | Issue 7 | Case Reports | 800 | Copyright © July 2018


Michelle W. Cheng BS,a Amy Kehl MD,b Scott Worswick MD,a Carolyn Goh MDa

aDavid Geffen School of Medicine UCLA, Los Angeles, CA bUCLA, Los Angeles, CA

non-responder. If possible, higher dose treatment may be helpful in these patients. Three other studies have documented use of high dose tofacitinib (>5 mg twice daily),7, 9-10 which demonstratedsimilar results.In addition, our study indicates that judicious use of ILK in combination with tofacitinib may be helpful in attaining complete disease resolution as four of five patients with adjuvant ILK achieved >90% change in SALT score. (Figure 1A/B) Finally, we observed lack of treatment durability following cessation of treatment, similar to previous reports.6,10Evidence for the use of topical JAK inhibitors in alopecia areata remains sparse. Currently, there exists a case series of pediatric patients treated with topical tofacitinib11 and two case reports in literature of patients with AAU treated with topical ruloxitinib12,13 0.6%, one reporting 10% hair regrowth12 and another reporting treatment failure.18 Only one of our four patients treated with topical tofacitinib 2% cream was observed to have hair regrowth (Figure 2A/B). However, the patient’s regrowth was robust with near complete resolution (post treatment SALT score 6.5%, 91.1% improvement in SALT score). During this period, the patient remained on several natural supplements which he had been taking prior to initiation of topical tofacitinib. No adverse effects were reported in this group.This study also shows that most patients tolerated the medication well. While there is increased risk of serious infection and increased malignancy with higher dose oral tofacitinib, the safety of tofacitinib at 10 mg twice daily dosing has been demonstrated to be comparable to standard dosing in several clinical trials including phase IIa and IIb trials in psoriasis.14 Notably, several of our patients were trialed on slightly higherdoses (11 mg extended release twice daily). Of our patients on higher dose regimens, only one experienced an adverse effect (hyperlipidemia), which was mild. Notably, one patient developed multiple sclerosis (MS). Whether this can be attributable to the drug is unclear, particularly as the JAK/STAT pathway has been identified as a possible therapeutic target in animal models of MS.15Tofacitinib administered orally and topically are exciting and promising treatment options for patients with longstanding, refractory AA. Additional studies are necessary to evaluate the safety and efficacy of JAK inhibitor treatment at both standard and higher doses. Topical tofacitinib may be an option for patients who cannot afford systemic tofacitinib treatment or tolerate the adverse effects. Given the apparent lack of durability following treatment cessation, long term studies of safety will be particularly important.

DISCLOSURES

The authors have no conflicts of interest to declare.

REFERENCES

  1. 1. Gupta, A.K., J.L. Carviel, and W. Abramovits, Efficacy of tofacitinib in treatment of alopecia universalis in two patients. J Eur Acad Dermatol Venereol. 2016;30(8):1373-8.
  2. Harris, J.E., et al., Rapid skin repigmentation on oral ruxolitinib in a patient with coexistent vitiligo and alopecia areata (AA). J Am Acad Dermatol. 2016;74(2):370-1
  3. Jabbari, A., et al., Reversal of Alopecia Areata Following Treatment With the JAK1/2 Inhibitor Baricitinib. E Bio Medicine. 2015;2(4):351-5.
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  14. K.A. Papp, M.A. Menter, M. Abe, et al. Tofacitinib, an oral Janus kinase inhibitor, for the treatment of chronic plaque psoriasis: results from two randomized, placebo-controlled, phase III trials. Br J Dermatol. 2015;173:949-961.
  15. Liu Y, Holdbrooks AT, De Sarno P, et al. Therapeutic Efficacy of Suppressing the JAK/STAT Pathway in Multiple Models of EAE. J Immunol. 2014;192(1):59-72.

AUTHOR CORRESPONDENCE

Carolyn Goh MD CGoh@mednet.ucla.edu
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