Sisaipho alopecia areata treated with tofacitinib and oral minoxidil.

Introduction

Alopecia areata (AA) is an autoimmune condition characterized by nonscarring hair loss that can be difficult to treat. Typical AA is characterized by round patches of alopecia on the scalp and, when severe, can manifest complete or near-complete hair loss on the scalp. AA may occur in distinctive patterns, such as the relatively common ophiasis AA, in which hair loss occurs in a band-like pattern on the occipital and temporal scalp. Sisaipho (ophiasis spelled backwards) is a rare variant of AA in which hair loss involves the top of the scalp, sparing the temporal and occipital areas.

Recently, Janus kinase (JAK) inhibitors have emerged as a promising treatment approach for AA.1, 2, 3 However, the efficacy of this therapeutic approach for sisaipho AA has not been described. Here, we report a case of a woman with sisaipho AA who experienced near-complete hair regrowth with tofacitinib 5 mg twice daily.

Case report

A 51-year-old woman with a 22-year history of AA presented for evaluation. Physical examination showed hair loss involving mainly the top of the scalp, with a Severity of Alopecia Tool (SALT) score of 50 (Fig 1, A). Her eyebrows and eyelashes were unaffected. She had previously been treated with intralesional triamcinolone without benefit. She was treated with combination spironolactone 100 mg twice daily and oral minoxidil 5 mg twice daily for 1 year without significant improvement. Following a discussion of the potential risks, the patient was started on tofacitinib 5 mg twice daily while continuing the oral minoxidil and spironolactone. After 4 months, there was significant hair regrowth (Fig 1, B) that continued to improve over time (Fig 1, C).

Fig 1

Clinical images showing the extent of scalp alopecia at presentation (A), after 4 months taking tofacitinib (B), and after 17 months taking tofacitinib (C).

Discussion

To our knowledge, this is the first report of a patient with sisaipho AA successfully treated with a JAK inhibitor (in combination with oral minoxidil). Prior reports have suggested that combination tofacitinib and oral minoxidil may be more effective than tofacitinib monotherapy for the treatment of AA., It is significant that after nearly 22 years of fixed hair loss (ie, there had not been hair growth involving the top of the scalp since shortly after it occurred), she experienced near-complete regrowth in a relatively short period of time; we attribute this to combination treatment. Notably, a previous study included 3 patients with ophiasis pattern AA who achieved similar results with tofacitinib. This report adds to the growing literature demonstrating the efficacy of JAK inhibitors for the treatment of AA.1, 2, 3

Conflicts of interest

RT has no conflicts of interest to declare. WD has research funding from Pfizer, is a consultant for Eli Lilly and Twi Biotechnology, and receives licensing fees from EMD/Sigma/Millipore in unrelated work. BK has served on advisory boards and/or is a consultant and/or is a clinical trial investigator for AbbVie, Aclaris Therapeutics Inc, AltruBio Inc, Almirall, Arena Pharmaceuticals, Bioniz Therapeutics, Bristol-Meyers Squibb, Concert Pharmaceuticals Inc, Dermavant Sciences Inc, Eli Lilly and Company, Incyte Corp, LEO Pharma, Otsuka/Visterra Inc, Pfizer Inc, Regeneron, Sanofi Genzyme, TWi Biotechnology Inc, and Viela Bio. He is on speaker bureaus for Eli Lilly, Incyte, Pfizer, Regeneron, and Sanofi Genzyme.