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When you look in the mirror, you think your mind is playing tricks on you
– could it be that your hair is starting to thin from the top and recede from
You shrug it off, thinking it might just be
just the light, or your imagination. Soon,
you notice those few extra hairs on your
pillow in the morning, and then there is
all the hair that is clogging your drain.
There is an undeniable difference, and
you come to the realisation that you are
losing your hair.
Even when no other conditions are
involved, for most people, hair loss can
be extremely distressing and anxiety
inducing at the best of times. Baldness
typically refers to hair loss from the
scalp (alopecia totalis), while hair loss
affecting the entire scalp and the whole
body is termed alopecia universalis.
Patterned, diffuse or patchy
Hair loss on the scalp can be described
as patterned, diffuse or patchy; and
clinical features are used to differentiate
between conditions. For instance,
alopecia areata is localised or patchy hair
loss and dermatoscopy shows hairs that
are tapered at the surface of the scalp.
Hair loss may also be evident in other
areas of the body e.g. eyebrows and eye
lashes. Alopecia areata is a complicated
autoimmune condition involving
multiple genes, but the environmental
trigger to express these genes is not
known. The hair loss is associated with
inflammation of the hair bulbs, which
cause the hair to stop growing and
shed prematurely. Some patients may
respond to a 3–4 month treatment
with potent topical corticosteroids
that suppress inflammation.
However, for patients who do not
respond to the topical corticosteroids,
have new or expanding patches are
referred to specialists for intralesional
and systemic corticosteroids,
diphencyprone immunotherapy (diverts
the inflammation response away from
the hair bulbs), minoxidil (enlarges
minaturised hair follicles and increases
the growth part of the hair life cycle)
and immunosuppression therapy.
Janus kinase inhibitors, which reduce
the effect of pro-inflammatory
cytokines and immune response have
also reportedly shown promise for
stimulating hair growth.
A case report describes a 25 year-old
male with no eyebrows, eyelashes, facial
hair; nor hair on his arms, legs, body,
armpit or groin. He sought treatment
for plaque psoriasis (started five years
earlier), and also had alopecia areata
alopecia from the age of two years
and alopecia universalis since he
was 18 years of age. Topical steroids
were ineffective for both conditions
and adalimumab was progressively
less effective for managing psoriasis.
Researchers sought a therapeutic agent
that could target both the psoriasis and
alopecia concurrently, and identified
tofacitinib – a Janus kinase inhibitor
approved for rheumatoid arthritis.
After three months of treatment,
significant regrowth of hair was noted.
After eight months, hair at all body
sites where there had been hair before
the onset of alopecia universalis had
completely regrown. The patient
tolerated tofacitinib and laboratory
monitoring results were uneventful.
The positive results on both the psoriasis
and hair regrowth from this case report
has led to several clinical trials on the
use of tofacitinib in moderate to severe
alopecia areata, totalis and universalis
(Columbia University, estimated
completion date December 2016), and
tofacitinib for the treatment of alopecia
areata and variants (Yale University,
estimated completion date July 2015;
and Stanford University, estimated
completion date December 2015). These
clinical trials will begin to shed more
light on the effectiveness of tofacitinib
on alopecia, and whether if / how
tofacitinib (or Janus kinase inhibitors)
fit into to the management plan for
patients with hair loss.
Tofacitinib dosing information
NB: dose adjustment required
for renal or moderate hepatic
impairment, and if patient is
taking concomitant therapy
with some CYP inhibitors.
5 mg twice daily for two
months, increasing to 10
mg in the morning and
5 mg at night
5 mg twice daily
* Tofacitinib does not have an indication for this
condition – dose provided is indicative only.
1. Craiglow BG, King BA. Killing two birds with one stone: oral
tofacitinib reverses alopecia universalis in a patient with a
plaque psoriasis. J Invest Dermatol. 2014;134:2988–90 .
2. Jabbari A, Dai Z, Xing L, et al. Reversal of alopecia areata
following treatment with JAK1/2 inhibitor baricitinib.
EBioMedicine. 2015;2:351–5 .
3. Mirmirani P. Two birds that exclude each other: the Renbök
phenomenon. J Invest Dermatol. 2015;135:1180.
» OLD DRUG NEW INDICATION
Prof Lisa Nissen and Dr Esther Lau are from the
School of Clinical Sciences, Queensland University of
Technology, Brisbane Queensland.
Tofacitinib for a new crop of
BY PROFESSOR LISA NISSEN & DR ESTHER LAU
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