Baricitinib for Pediatric Patients with Severe AA

New Study Supports Effectiveness of Baricitinib in Pediatric Patients

JAK inhibitors are increasingly used for the treatment of severe AA. In 2023, the JAK inhibitor ritlecitinib became the first drug approved by FDA for treating alopecia areata in individuals in the 12 - 18 age group. Of course, the drug is approved for adults as well. But what’s unique about ritlecitinib is its approval in the 12-18 age group.

I can only imagine that we’ll be seeing more and more and more approvals for alopecia areata drugs in the pediatric population. Advanced alopecia areata affects a significant number of children. Children and adolescents respond just as well to these drugs as adults - and have fewer side effects.

Baricitinib for Alopecia Areata in Pediatric Patients.

It should be no surprise then that a handful of studies have already emerged examining the benefits of baricitinib in the treatment of alopecia areata in children and adolescents.

A new study from China reported outcomes of 10 pediatric patients with severe AA receiving baricitinib. Patients ranged in age from 1 year and 10 months to 13 years so there were some pretty young patients in this study. In fact, 75% were under 6.5 years. There were 5 male patients and 5 female patients.

The median baseline SALT score was 87.50 indicating fairly advanced AA to start with. The median age of onset of AA was 3 years and the median duration of the current episode of AA was 3 months. Most patients had been on other treatments before starting baricitinib, including topical steroids (8 patients), steroid injections ( 8 patients), oral steroids (4 patients), methotrexate (2 patients and tofacitinib (1 patient).

In this study, pediatric patients received 2 mg per day except for 1 patient who failed 2 mg and received 4 mg. Unfortunately, the exact protocol of this study was not clear to me. It appears the authors reduced the dose to half in patients who achieved a SALT score of 20 or less at 12 weeks.

All in all the median duration of treatment was 15 months. At week 36, 80 % of patient had a SALT score 20 or less.

Side effects were mild and just one patient experienced temporary mild neutropenia.

What was interesting in this study is what happens when the drug is stopped. Patients in this study were followed to see what happens after the drug is stopped. 4 of 9 patients still had complete remission with a follow-up of 22.5 months. 5 patients relapsed after stopping the drug, with an average time to relapse of 14.2 months.

COMMENT

This is another study for the books for JAK inhibitors in young children. I suspect this will be an increasing trend in our field. I’m not particularly focused on the great success of JAK inhibitors in this particular study because it included some patients with less severe forms of AA and the average (median) duration of alopecia was just 3 months. Clearly we expect better success in less severe forms and those with shorter duration of AA. Nevertheless, this study is a nice reminder that JAK inhibitors tend to be well tolerated in children, but lifelong treatment is probably going to be the norm for most patients with severe forms of AA. Long-term side effects of continuous JAK inhibitor therapy are completely unknown at the present time.

REFERENCES

Zhao M et al. Baricitinib therapy for paediatric patients with severe alopecia areata. J Eur Acad Dermatol Venereol. 2024 May 22.

Zhan J et al. Real-data on the use of baricitinib in adolescents with severe alopecia areata. J Eur Acad Dermatol Venereol. 2023 Apr 17. doi: 1

Moussa A et al.Treatment of moderate-to-severe alopecia areata in adolescents withbaricitinib: a retrospective review of 29 patients. J Am Acad Dermatol.2023;88(5):1194–6.3.

Asfour L et al.Treatment of moderate-to-severe alopecia areata with baricitinib in preadolescent children. Br J Dermatol. 2023;189(2):248–50