LAUSR

SALT, Severity of Alopecia Tool. To the Editor: Alopecia areata, especially alopecia universalis, can be challenging to treat in children and adolescents. Standard therapies, including oral, topical, and intralesional corticosteroids, usually fail or have high relapse rates. Contact sensitization and systemic immunosuppression do not improve outcomes for most patients. The systemic janus kinase (JAK) inhibitors tofacitinib and ruxolitinib are novel therapies reported to be of benefit in case reports and small clinical trials of alopecia areata in adults and a small number of adolescents. They are approved by the US Food and Drug Administration for patients $18 years of age with rheumatoid arthritis and have been used to treat other autoimmune diseases, including psoriasis. The average cost of systemic JAK inhibitors is about $2200 per month. There is an ongoing trial to evaluate their safety in children and adolescents with juvenile idiopathic arthritis. We report a case series of 8 adolescent patients 12 to 19 years of age with alopecia universalis treated with oral tofacitinib. Alopecia universalis had been present for[1 year (range, 1-10 years). All patients had 100% hair loss at baseline and had failed oral pulsed steroids, topical steroids, and topical immunotherapy. Four patients had failed methotrexate therapy for 6 months; 2 had failed a 6-month trial of hydroxychloroquine; and 2 had failed topical tofacitinib therapy. This study was approved by the Institutional Review Board of the Children’s Hospital of Philadelphia. Treatment was with tofacitinib 5 mg twice a day for 5 to 18 months (Table I). Complete blood cell count, metabolic panel, and serum lipids were assessed before initiation and at 1 month, 3 months, and every 3 months thereafter of therapy. No changes were noted in laboratory values from baseline. No adverse events or infections were reported. All patients had [50% regrowth in scalp hair by 5 months and a significant improvement in the Severity of Alopecia Tool (SALT) scores at each visit. In all patients, slow but significant hair regrowth was noted in the first 3 months followed by more rapid regrowth after that time. No patient achieved 100% regrowth of scalp hair. Two patients, 1 on treatment for 18 months (Fig 1) and the other for