Is tapering and stopping of tofacitinib possible among pediatric and adolescent alopecia areata patients?

Dear Sir,

Alopecia areata (AA) is an autoimmune condition characterized by non-scarring patchy alopecia. The condition affects all age groups, and an early age of onset (<12 years) is associated with an increased risk of developing chronic alopecia areata (CAA) and alopecia Totalis/universalis (AT/AU), which may lead to a poor response to therapy.^[1] Among all patients of AA, almost half experience disease onset within the first two decades of life, making it the most common cause of alopecia in children.^[2] The various available treatment options for moderate to severe AA include topical immunotherapy/contact irritants, systemic steroids, and steroid-sparing agents like cyclosporine, azathioprine, methotrexate, and the Janus kinase inhibitors.

There are a few studies that have shown the safety and efficacy of janus kinase inhibitor (JAKi) in pediatric and adolescent populations.^[3,4] However, there is no data available on tapering and stopping of tofacitinib and management of patients post stopping. A study found that JAK1i or JAK3i treatment significantly decreased the frequency of resident memory T cells (TRM) in the skin and thus may decrease the chances of relapses. However, a small number of pathogenic TRM may persist in the skin even after successful JAKi treatment, which may become reactivated after stimulation by recovered hair follicle (HF) autoantigens upon withdrawal of JAKi treatment, leading to disease relapse.^[5] In this retrospective study, we report our experience of tapering and stopping tofacitinib among pediatric and adolescent patients.

In this study, patient records were reviewed to identify patients with AA < 18 years who were treated with systemic tofacitinib for at least 6 months between January 2021 and July 2024 at a tertiary care hospital. A total of 31 such patients were identified; among these 31 patients, 11 patients (35.4%) achieved complete regrowth. The mean age of these 11 patients was 9.27 years (range 4 -17 years), and 8 were boys, and 3 were girls. The mean baseline severity of alopecia tool (SALT) score for these patients was 55.5 (range 8.2-100). Among these 11 patients, the mean duration of tofacitinib treatment was 11 months (range 4 - 24 months), while the mean tofacitinib dose was 5.9 mg/day (range 2.5 - 10 mg/day). Tofacitinib was stopped in all these 11 patients; the mean duration since these patients are off tofacitinib is 11.5 months (range 2-28 months). Patient characteristics are mentioned in Table 1.

Post stopping of tofacitinib, 5 of 11 patients (45.4%) didn’t show any relapse till the collection of data. The mean duration since these patients are off tofacitinib is 12 months (range 7-24 months). Of these 5 patients, three had reticular AA: one with severe grade (i.e., involvement >50%) and two with moderate grade (i.e., 20-50% involvement). Two had multiple patch AA (moderate grade with involvement <20% but multifocal hair pull test positive). The mean disease duration in these patients was 16.6 months (range 2-48 months), and the mean baseline SALT score was 39.82 (range 8.7-77.4).

The remaining 6 out of 11 patients showed relapse within a mean duration of 5 months (range 2- 28 months) of stopping tofacitinib. However, the relapse in these patients was that of a mild disease ( area < 20%) with a mean SALT score of 3 (range 1.2 - 7.2) and didn’t require restarting of tofacitinib. Out of these 6 patients, 3 had reticular AA with severe grade, i.e., involvement >50%, 1 had AT, 1 had subtotalis, and 1 had multiple patch AA with moderate grade ( involvement < 20% but multifocal hair pull test positive). The mean disease duration in these patients was 13 months (range 2-24 months), and the mean baseline SALT score was 68.63 (range 8.2-100). Post relapse, all 6 patients received short-contact dithranol therapy. Additionally, 1 patient received an intralesional triamcinolone injection, 2 received topical steroids, and 2 patients received topical minoxidil with adequate response.

Comparing the characteristics of patients who did not show relapse to patients who showed relapse, a conclusion can be drawn that in patients with less severe baseline disease (lower SALT scores and not Totalis/universalis), tapering and stopping of tofacitinib is a possibility. Though relapses are common in AA, in our study, all the relapses were mild with no requirement of restarting tofacitinib.