Adjuvant oral minoxidil for the treatment of alopecia areata refractory to Janus kinase inhibitors

Received on: 11/01/2020
Approved on: 10/03/2020

Financial Support: BAK received funding support from The Ranjini and Ajay Poddar Resource Fund for Dermatologic Diseases Research
Conflict of interest: BAK and CGW are investigators for Concert Pharmaceuticals Inc., Eli Lilly and Company and Pfizer Inc. BAK is a consultant to and/or has served on advisory boards for Aclaris Therapeutics, Concert Pharmaceuticals Inc., Dermavant Sciences, Aclaris, Eli Lilly and Company, Pfizer Inc.; BAK and BGC are on speaker bureau for Pfizer Inc., Regeneron, Sanofi Genzyme. BGC is a consultant and has served on advisory boards for Pfizer Inc

Research conducted at the Department of Dermatology, Yale School of Medicine, Yale University, New Haven, CT, USA

Abstract

Janus kinase inhibitors have changed the therapeutic paradigm of severe alopecia areata therapy. Some patients are refractory to dosage escalating. In this article, we describe the applicability of adjuvant oral minoxidil therapy.

Keywords: Alopecia; Alopecia Areata; Hair Janus Kinases; Minoxidil

While Janus kinase (JAK) inhibitors have changed the therapeutic landscape of severe alopecia areata (AA), not every patient with AA responds to JAKi, and other treatment challenges remain: (1) Some patients require increased doses of JAK inhibitor to achieve hair regrowth; (2) Disease relapse can occur despite ongoing treatment; (3) If disease relapse occurs after treatment discontinuation, the same hair regrowth as occurred with initial treatment may not occur with retreatment.

In 1987, a study of oral minoxidil, 5mg twice daily, for the treatment of AA showed that 20% of patients achieve cosmetically acceptable hair growth.1 Recently, we observed that tofacitinib used in combination with oral minoxidil may be more efficacious than tofacitinib monotherapy in patients with severe AA.2 Here we present 3 patients with AA undergoing monotherapy with tofacitinib or ruxolitinib in which there was no efficacy or waning efficacy; in each case, adding (adjuvant) oral minoxidil (AOM) produced an excellent response (Figures 1 and 2).

In some patients who are refractory to JAKi monotherapy, AOM may offer a solution. In our experience, the response to adjuvant treatment is typically seen 3-6 months after initiation of

AOM (2,5mg, once or twice daily). Combination therapy may improve efficacy of JAKi, thereby limiting the need to escalate dosage, which is costly and potentially increases the risks for adverse effects. Additional studies will be important to better understand the optimal use of oral minoxidil in combination with JAKi.

 

AUTHORS’ CONTRIBUTIONS:

Carlos Gustavo Wambier | ORCID 0000-0002-4636-4489
Statistical analysis; approval of the final version of the manuscript; study conception and planning; elaboration and writing of the manuscript; data collection, analysis, and interpretation; effective participation in orientation of the research; critical review of the literature; critical revision of the manuscript.

Brittany G. Craiglow | ORCID 0000-0001-8970-7691
Statistical analysis; approval of the final version of the manuscript; study conception and planning; elaboration and writing of the manuscript; data collection, analysis, and interpretation; effective participation in orientation of the research; critical review of the literature; critical revision of the manuscript.

Brett A. King | ORCID 0000-0002-4576-4616
Statistical analysis; approval of the final version of the manuscript; study conception and planning; elaboration and writing of the manuscript; data collection, analysis, and interpretation; effective participation in orientation of the research; intellectual participation in the propaedeutic and/or therapeutic conduct of the cases; critical review of the literature; critical revision of the manuscript.

 

REFERENCES

1. Fiedler-Weiss VC, Rumsfield J, Buys CM, West DP, Wendrow A. Evaluation of Oral Minoxidil in the Treatment of Alopecia Areata. Arch Dermatol. 1987;123(11):1488-90.

2. Wambier CG, Craiglow BG, King BA. Combination tofacitinib and oral minoxidil treatment for severe alopecia areata. J Am Acad Dermatol. 2019;pii:S0190-9622(19)32688-X. Epub 2019 Sep 6.