This episode, "Starting JAK Inhibitors for Alopecia Areata: Safety Counseling and Choosing an Agent," features Dr. Ungar describing his clinical experience and the practical steps of starting therapy.

Dr. Ungar describes his experience with these therapies as tremendously positive. Responses vary between patients, but he has seen the treatments transform lives, with some patients regrowing everything from large scalp areas to total body hair loss, including eyebrows and eyelashes. Patients often describe feeling dramatically better about their lives.

He then outlines challenges at initiation. The first is practical: access often requires prior authorizations and appeals, and manufacturers frequently offer bridge programs. For counseling, his starting point is acknowledging that alopecia areata is worth treating, because patients arrive having experienced its negative impact. Benefits provide the context in which risks should be weighed, and most patients are motivated to accept risk in order to respond.

Risks should still be reviewed using the safety data across all these agents, including placebo-controlled periods, extension studies, and real-world experience spanning thousands of patients. Dr. Ungar explains that none of the risks in the boxed warning, which did not originate from alopecia areata studies, have been shown to increase with JAK inhibitors in this disease. Individual risk factors such as age and cardiovascular disease still need to be considered, but the benefits generally outweigh the risks.

On agent selection, Dr. Ungar considers all three options very good, and a payer-preferred choice that ensures access matters more than the specific drug. Speed is paramount for the Case 1 patient, whose six-month window is short. Without comparing trials directly, he notes that deuruxolitinib reached statistical significance for regrowth at the earliest time point, so all else being equal he would start with it.

Up next, in "Case 2: Assessing Severity and Rapid Progression in Alopecia Areata," a 29-year-old woman's progression and social withdrawal test how severity is defined.