Tofacitinib

Tofacitinib (Xeljanz), a Janus kinase (JAK) inhibitor, has been studied off-label for alopecia areata (AA), alopecia totalis (AT), and alopecia universalis (AU). It is approved for rheumatoid arthritis and other immune conditions such as psoriatic arthritis and ulcerative colitis. It is not approved for alopecia areata in any country; any use for hair loss is off-label. Initially developed for the treatment of rheumatoid arthritis, its mechanism of action involves inhibiting the Janus kinase enzymes, which play a pivotal role in the signaling pathway that leads to inflammation. By interfering with this pathway, tofacitinib can reduce inflammation in several autoimmune conditions.

Tofacitinib carries an FDA boxed warning for serious infections including tuberculosis, higher all-cause mortality, malignancy (including lymphoma and lung cancer), major adverse cardiovascular events and thrombosis, based on a large rheumatoid-arthritis safety trial. The label calls for testing for latent tuberculosis before treatment, monitoring of blood counts, lipids and liver enzymes, and avoiding live vaccines. Anyone pregnant, planning pregnancy or breastfeeding should discuss this with the prescriber (Xeljanz prescribing information, DailyMed).

The role of tofacitinib in treating alopecia arises from its ability to interrupt the immune system's attack on hair follicles. Alopecia areata, an autoimmune condition, results in the body's immune system mistakenly targeting the hair follicles, leading to hair loss. Tofacitinib's action on the JAK pathways is thought to dampen this autoimmune attack while the drug is taken, which can allow hair follicles to re-enter the growth phase.

The evidence comes from small studies without control groups. In a retrospective series of 90 patients without a control group (Liu et al., 2017, Journal of the American Academy of Dermatology), the headline figures cover only the 65 patients the authors classed as potential responders (patchy alopecia areata, or alopecia totalis or universalis for 10 years or less): 77% of these showed some regrowth and 58% had more than 50% improvement in SALT score over 4 to 18 months. In a 2016 open-label trial without a control group, 32% of 66 patients had a 50% or greater improvement after three months (Kennedy Crispin et al., 2016, JCI Insight). However, it also highlighted that the likelihood of complete hair regrowth decreases with the duration of hair loss, especially after 10 years. In that trial, hair loss returned a median of 8.5 weeks after stopping. Keeping regrowth therefore means continuous use, which also means continuous exposure to the risks above.

The Tressless community's sentiment towards tofacitinib is one of cautious optimism. Discussions within the community reflect a diverse range of experiences, with many users sharing their personal success stories in regaining hair through tofacitinib treatment. These anecdotes often highlight the significant impact of tofacitinib on improving their quality of life, marking a stark contrast to the despair felt when other treatments failed. Nevertheless, community members also express concerns about the long-term implications and side effects of using JAK inhibitors, emphasizing the importance of informed decision-making and medical supervision.

In summary, tofacitinib is an early off-label option for severe alopecia areata whose benefits and risks in this condition have not been tested in large randomized trials. Other JAK inhibitors (baricitinib, ritlecitinib) have since been approved specifically for severe alopecia areata. Talk to a dermatologist before starting, stopping or combining tofacitinib or any JAK inhibitor.