SF Derm Society Annual Meeting Pearls
Hair Me Out—A Synopsis of Dr. Paradi Mirmirani’s ‘Hair Loss Updates’
Part I: Alopecia Areata & JAK inhibitors
Authors: Chandler Johnson, Paradi Mirmirani, MD
At the San Francisco Dermatological Society Annual Conference hosted in Half-Moon Bay, California on July 27, 2024, Dr. Paradi Mirmirani, MD led an informative lecture titled “Hair Loss Updates.” Dr. Mirmirani is a dermatologist and world renowned hair loss expert, serving as a scientific advisor for the Cicatricial Alopecia Research Foundation as well as an active member of the North American Hair Research Society and National Alopecia Areata Foundation. In Dr. Mirmirani’s lecture, she discussed three main topics of interest:
- Alopecia Areata and JAK-inhibitors
- Hair Loss and Low-Dose Oral Minoxidil
- Scarring Alopecia and Environmental Triggers
The following writing outlines clinical pearls as well as updates to topics related to hair loss—relevant to dermatologists, patients, and their advocates.
Alopecia Areata and JAK-inhibitors
Before 2022, there were no FDA approved treatments for alopecia areata; Now, there are three that are approved for severe alopecia areata.
- Ritlecitinib (brand name, Litfulo™): an oral JAK3 and TEC TK inhibitor, is FDA approved for patients with alopecia areata who are 12 and older.
- Baricitinib (brand name, Olumiant™): an oral JAK1 and JAK2 inhibitor, is FDA approved for patients with alopecia areata who are 18 and older.
- Deuruxolitinib (brand name, Leqselvi™): an oral JAK1 and JAK2 selective inhibitor, was FDA approved on July 26, 2024, for treatment of adults with severe alopecia areata.
Objectively, severity is assessed during clinical trials in part by using the Severity of Alopecia Tool (SALT) , which roughly translates to the percent of scalp hair loss. Moderate to severe alopecia is characterized by at least 50% or greater hair loss. Those individuals not meeting this criterion were not able to gain access to the clinical trials for enrollment. However, dermatologists will likely agree upon the fact that, clinically, severity is not based upon a SALT score; Instead, severity may be assessed by the gestalt of a patient’s clinical presentation, history, and lived experience with alopecia areata.
Recognizing the multi-factorial nature of defining severity, Dr. Mirmirani worked with a group of clinician specialists and industry partners to better define what severe means (see below list). Setting these parameters was understood to critical for being able to actually prescribe these medications in clinic and have them be covered by insurance.
- Percent of scalp involvement
- Psychosocial impact
- Noticeable involvement of the eyebrows or eyelashes (both being cosmetically sensitive areas)
- Tried and failed previous treatments
- Rapidly expanding area of hair loss
With the exciting opportunity to identify patients meeting severity criteria for alopecia areata who are interested in pursuing systemic therapy with a JAK-inhibitor, dermatologists may wonder how these may be best used in clinical practice. To offer relevant, concise advice to colleagues, Dr. Mirmirani compiled a list of top questions she has received on the topic:
- When do you use a JAK-inhibitor for a patient presenting with alopecia areata?
Dr. Mirmirani notes that JAK-inhibitor are typically not used as a first line treatment. Systemic corticosteroids remain a first line treatment mainstay: With this therapy, patients may have spontaneous remission of disease. However, if a patient has stable hair loss for at least 6 months, then they may be a better candidate for a JAK-inhibitor.
2. Which JAK-inhibitor should you use for a patient presenting with alopecia areata?
Dr. Mirmirani emphasizes that the choice of JAK-inhibitor truly is driven by which medication is accessible for the patients (and is most likely covered by insurance).
3. What if I have a patient showing hair regrowth on tofacitinib (brand name, Xeljanz™), but it is not FDA approved for treatment of alopecia areata—should I switch?
Dr. Mirmirani adheres to a treatment philosophy of not “rock[ing] the boat” if a patient is exhibiting a good response to the medication. It is only at a certain point where the patient may lose response that she may recommend a switch to one of the FDA approved JAK-inhibitors.
4. Do you combine JAK-inhibitors with other treatments?
Simply put, yes! Dr. Mirmirani recognizes the importance of combining or “stacking” treatments for the best patient outcomes.
"Dr. Mirmirani recognizes the importance of combining or “stacking” treatments for the best patient outcomes."
5. How long should I tell patients to wait before they should start seeing results?
Well-known to dermatologists, is the slow, tedious process of anticipating results for hair regrowth. The earliest that individuals may see results is 3 months. However, to better brace patients for the process, Dr. Mirmirani instructs patients to anticipate a wait of at least 6 months, and even up to 9 months, before they see results of treatment.
6. When should I tell patients they can stop their JAK-inhibitor?
Experts have yet to determine an exact, agreed-upon plan for the discontinuation of JAK-inhibitors. Some clinicians may recommend a slow taper only if the patient has not had any patchy hair loss for >1 year: Have a patient stop one day a week for 2 to 3 months, and if they have no patches and no shedding, then may continue with a slow taper. Of course, there are some instances where patients must stop treatment such as with pregnancy, loss of insurance coverage, or inability to access medication. In these instances, it is recommended that providers reassess the patient when the patient may be able to resume treatment.
7. What about the black box warning?
As always, a careful review of the medical history and shared decision making is key when approaching the black boxing warning for these medications.
8. What is the approach to forming a treatment plan for a patient who qualifies for treatment with a JAK-inhibitor?
- It is important that a patient has “foundational treatment” for their alopecia areata, which may be composed of one or multiple of the below-mentioned medications:
- Systemic corticosteroids
- Topical immunotherapy(squaric acid or diphenylcyclopropenone)
- Short contact anthralin
- JAK-inhibitor
- Of note: It is encouraged to mix, match, combine and personalize treatment for a given patient; It is understood that by stacking treatments, JAK-inhibitor efficacy is improved.
9. What if a patient presents with a concerning history of having either history of blood clots, spontaneous abortion, or breast cancer?
- A JAK-inhibitor may not always be a good choice for patients given their medical history or comorbidities. In these instances, considering dupilumab may be an option. Dr. Mirmirani mentions that initial reports suggest that dupilumab may be most effective when patients have an elevated specific or total IgE
A Reference of Organizations:
- National Alopecia Areata Foundation: https://www.naaf.org/
- Scarring Alopecia Foundation (SAF): https://scarringalopecia.org/
- American Hair Research Society: https://americanhairresearchsociety.org/
ORCiDs
CEJ, https://orcid.org/0009-0000-5818-8710
PM, https://orcid.org/0000-0001-8627-2995