An Open-Label Pilot Study to Evaluate the Efficacy of Tofacitinib in Moderate to Severe Patch-Type Alopecia Areata, Totalis, and Universalis

Abstract

Alopecia areata (AA) is a common autoimmune disease with a lifetime risk of ∼2%. In AA, the immune system targets the hair follicle, resulting in clinical hair loss. The prognosis of AA is unpredictable, and currently there is no definitive treatment. Our previous whole genome expression studies identified active immune circuits in AA lesions, including common γ-chain cytokine and IFN pathways. Because these pathways are mediated through JAK kinases, we prioritized clinical exploration of small molecule JAK inhibitors. In preclinical trials in mice, tofacitinib successfully prevented AA development and reversed established disease. In our tofacitinib trial in 12 patients with moderate to severe AA, 11 patients completed a full course of treatment with minimal adverse events. Following limited response to the initial dose (5 mg b.i.d.), the dose was escalated (10 mg b.i.d.) for nonresponding subjects. Eight of 12 patients demonstrated ≥50% hair regrowth, while three patients demonstrated <50% hair regrowth, as measured by Severity in Alopecia Tool scoring. One patient demonstrated no regrowth. Gene expression profiles and Alopecia Areata Disease Activity Index scores correlated with clinical response. Our open-label studies of ruxolitinib and tofacitinib have shown dramatic clinical responses in moderate to severe AA, providing strong rationale for larger clinical trials using JAK inhibitors in AA. ClinicalTrials.gov ID NCT02299297.

Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1.. Clinical progression of therapeutic response to Tofacitinib and relapse after discontinuation.

(a) Relapse after treatment was stopped on week 24. (b) Relapse after treatment was stopped on week 50.

Figure 2.. Severity of alopecia tool (SALT) scores for individual patients.

(a) during treatment (solid lines) and following cessation of (dashed lines) tofacitinib treatment. An “X” corresponding to each respective patient line indicates time at which treatment was stopped. In the event of a patient dropping out of the study prior to tofacitinib discontinuation or being lost to follow up, the “X” is placed at the end of the patient line. (b) Percentage regrowth for individual patients during and following cessation of tofacitinib treatment.

Figure 3.. Molecular analysis of skin biopsies taken from patients during a clinical trial of tofacitinib citrate.

(a) 24 weeks of treatment corresponds with significant shifts in molecular profile of scalp biopsies. (b). ALADIN signature scoring accurately predicts and reflects response to treatment using a disease signature.