Topical tofacitinib for FFA : Yes, it's on the list!

Topical tofacitinib for LPP and FFA

Oral and topical JAK inhibitors continue to be studied in scarring alopecia. A small number of studies point to potential benefits of oral and topical JAK inhibitors in the treatment of lichen planopilaris and frontal fibrosing alopecia. Topical JAK inhibitors have an obvious interest given that they have less systemic absorption than oral JAK inhibitors. This is important given that oral JAK inhibitors come with their share of side effects including infections, blood test abnormalities, and other issues. To date, there have only been a limited number of patients who have been reported to use topical JAK inhibitors to treat their scarring alopecia. These were 2 cases of women with FFA who showed improvement with the use of tofacitinib 2% cream.

Li-Chi Chen et al. 2024

A new study from Boston retrospectively examined how well patients did with topical tofacitinib treatments. There were 37 female and 4 male patients in this study. Most were white (90.2%). Most had FFA (75.6%), or LPP/FFA overlap (17.1%). 7.3 % had classic LPP without typical FFA. The average age at diagnosis was 57.8 years and the mean disease duration was 4.6 years.

Topical tofacitinib 2% cream was used as the sole therapy in one-quarter of patients (24.4%) and as an adjunctive treatment in three-quarters of patients (75.6%). The average duration of treatment duration was 9.0 months. 60 % used the topical tofacitinib 2-3 times daily, and 40 % used it 1-2 times daily.

All in all patients using topical tofacitinib demonstrated a significant reduction in LPPAI scores after receiving topical tofacitinib. LPPAI scores fell from 3.03 before treatment to 1.40 after treatment. This represented a 48% decrease in LPPAI score at 6 months

What was more important in this study was the data on hairline outcomes. Topical tofacitinib seemed to help stop the progression of hairline recession. Of 38 patients with FFA or FFA/LPP overlap, 31.6% had improvement and 60.5% had stabilization of the frontotemporal hairline. About 8% of patients using topical tofacitinib really didn’t see much benefit. Side effects were mild and included irritation in 2 patients and acne in 1 patient. 1 patient ultimately discontinued the treatment due the scalp irritation.

COMMENT

I really liked this study. It shows clear evidence that topical tofacitinib does something positive for patients with FFA and LPP. Almost 60% of patients in this study were using topical tofacitinib twice per day - so this is a pretty committed group. Topical tofacitinib is not cheap - so this sort of dedication sure comes with a cost.

I like this study because it gives me practical and useful information to share with patients. At least in this study 41.6% of patients had improvement and 60.5% had stabilization of the frontotemporal hairline. I’m always a bit skeptical of data on stabilization as it can take 2 years to really confidently prove there is stabilization, but certainly, the data on improvement and the overall trend is really encouraging.

I’ve been using topical tofacitinib in several of my FFA patients with reasonable benefit in some patients but not all. One problem of using topical tofacitinib is that there is no standard formula. I have creams and gels in my toolbox and they sure seem to work differently in different patients. This is the main problem with all topical compounded products. My topical tofacitinib is different than the topical tofacitinib used in this particular study - so is this study relevant to my own patients? Probably there is some relevance!

In conclusion, this is the first good size study of topical tofacitinib in FFA/LPP.

REFERENCES

Li-Chi Chen, Chino Ogbutor, Kristen J Kelley and Maryanne M Senna. Topical tofacitinib for patients with lichen planopilaris and/or frontal fibrosing alopecia. J Am Acad Dermatol. 2024 Jun;90(6):1260-1262. doi: 10.1016/j.jaad.2024.01.060. Epub 2024 Feb 2.

Yang C.C., Khanna T., Sallee B., Christiano A.M., Bordone L.A.: Tofacitinib for the treatment of lichen planopilaris: a case series. Dermatol Ther 2018; 31:

Moussa A., Bhoyrul B., Asfour L., Kazmi A., Eisman S., Sinclair R.D.: Treatment of lichen planopilaris with baricitinib: a retrospective study. J Am Acad Dermatol 2022; 87: pp. 663-666.

Plante J., Eason C., Snyder A., Elston D.: Tofacitinib in the treatment of lichen planopilaris: a retrospective review. J Am Acad Dermatol 2020; 83: pp. 1487-1489.