Expectations of JAK inhibitor treatment of alopecia areata

Transcript: Expectations of JAK inhibitor treatment of alopecia areata (March 12, 2025)
LISA ANDERSON, PhD:

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Welcome to the National Alopecia Areata Foundation webinar, Expectations of JAK Inhibitor Treatment of Alopecia Areata. Joining us today is Dr. Brett King, and I'm Lisa Anderson, Senior Director of Research for NAAF. Before we start the webinar, I'd like to cover a few housekeeping details. We've disabled chat for this webinar session.

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Please post questions for Dr. King in the Q&A section, and please try to keep your questions general for the benefit of all audience members. This webinar is being recorded, and all registrants will receive a link to the recording via email. And finally, please share your feedback with us. At the conclusion of the webinar, a link to a short survey will pop up in your browser window.

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Please complete the survey there. This webinar is part of NAAF's You Are Not Alone Education and Empowerment webinar series. NAAF gratefully acknowledges the support provided for this webinar series by our partners Lilly, Pfizer, and Sun Pharma. Before we get started, I'd like to tell you a bit about NAAF and our mission.

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The National Alopecia Areata Foundation is the leading advocacy organization for alopecia areata. NAAF's mission is to drive research to find a cure and accessible treatments for alopecia areata. Support those impacted and educate the public about the disease. NAAF's vision is an empowered community with a choice to embrace or live free of alopecia areata.

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To learn more about NAAF's support resources and research and advocacy activities, or to join us as an advocate or a supporter, please visit our website at naaf.org. And now on to today's webinar. Expectations of JAK inhibitor treatment of alopecia areata. We're excited to have Dr. Brett King back with us today.

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As you may already know, Dr. King pioneered the use of JAK inhibitors in dermatology as the first dermatologist to show that they were effective for the treatment of alopecia areata, vitiligo, eczema, and other diseases. He has also advanced the use of oral minoxidil for the treatment of male and female pattern hair loss and other forms of hair loss.

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After completing his medical training, Dr. King spent 14 years on the full-time faculty at the Yale School of Medicine. Before recently transitioning to private practice in order to focus on patient care, clinical research, and medical education. He's been an investigator in numerous clinical trials, including those leading to FDA approval of Olumiant and Litfulo for the treatment of alopecia areata.

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Dr. King was named an American Academy of Dermatology patient care hero for his work, treating patients with severe alopecia areata. We are fortunate to have him as a member of NAAF's board of directors and research advisory council. Dr. King, thank you so much for being here today. I'm going to stop sharing and I will turn it over to you.

DR. BRETT KING:

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All right. Thank you so much, Lisa. And thank you to everyone who is here. Perfect. I'm super excited to be here. Really this is an area that is very near and dear to my heart and I've taken care of and continue to take care of hundreds and hundreds of people with alopecia areata and it really is where I spend all of my time and as far as we have come in a short period of time, we have a long way to go.

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But again, we have come a really long way in a short period of time. And fortunately, that means that we have a lot of data to guide how we should be doing this. But because we have come so far. In so short a time, it means that dermatologists are not very familiar with how to do this. Dermatologists are, by and large, not very familiar with the care of people with severe alopecia areata, and their treatment.

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with JAK inhibitors. It's not a statement that we're not going to get there. What you have to consider is that in dermatology, we have medicines that make psoriasis better in a month. Literally, we can take somebody who is covered from head to toe with red scaly skin, and we can make it vanish in a month.

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We can take people who are itchy and red and scratched up from eczema and make them better in a month or two. And those were the big advancements. Leading up to the last few years when we've been able to regrow hair in people with severe alopecia areata. And so what is the dermatologist thinking? The dermatologist who's not deeply familiar with treatment of alopecia areata, their experience is, “Oh, when I give this medicine to regrow hair, somebody's hair is going to regrow in a month or two or three, because that's how long it takes to make our patients with eczema or psoriasis better.”

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But that's just not the case. And so what we're going to spend our time doing in the next 30 to 40 minutes and then have some time for questions and answers is to review what do we know about what to expect from treatment of alopecia areata.

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This is our agenda. We have a lot of ground to cover and we're going to start, actually, before we get into kind of the meat of the talk, we're going to start with highlights from a big meeting that I just returned from yesterday. It was an annual meeting in Orlando, Florida, sponsored by the American Academy of Dermatologists.

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It draws 18 to 20, 000 dermatologists from the U. S. and around the world to a three or four or five day meeting covering everything there is to talk about in skin. Because alopecia areata is an interesting topic and there's a lot of innovation happening here, there were some really interesting talks at the meeting and we're going to cover those very briefly. So before we get into everything, I just like to do this before every one of the talks that I've done in this setting.

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And that is just to be sure that we're all on the same page. These are the different ways that alopecia areata can present. We have the person here in the upper left-hand corner with one, two spots of hair loss. For sure. That's the most common presentation. Everybody else on this screen represents other manifestations or severities of alopecia areata, right?

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This person here in the lower left-hand corner has a lot more than one spot and they've run into each other. This person here in the middle upper panel has an ophiasis pattern, right? That's the pattern that sort of along the back bottom part of the scalp and runs up over the ears. And then of course people can just have diffuse loss, not necessarily spots at all, but just diffuse loss.

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And then of course people can lose all of the hair on their scalp. And then of course, any other area that bears hair can also be involved as can the nails.

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And now here, this is the last introductory slide, just so that everybody on the call understands alopecia areata includes the person with one spot, the person with many spots that have run into each other to form large areas of loss, it includes this person with ophiasis pattern, and it includes this a person in the lower right-hand corner who has complete scalp hair loss, and maybe complete scalp hair and complete eyebrows and eyelashes and body hair loss.

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All of those people have alopecia areata. When we use those words, we mean everybody on this page. It's just a matter of how severe is the loss for any particular person. Okay, so let's dive into the highlights from the American Academy of Dermatology meeting. And really, the point of this slide is just to illustrate that again, and I'm going to say this a lot because I think it's what's so exciting.

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We've come so far in so short a time. But, we have a long ways to go, and these are highlights of the future. So on the left, the box says, Signal AA, a phase 2a randomized placebo-controlled trial of a medicine called, named bempikibart, for patients with severe or very severe alopecia areata.

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This was really exciting and provocative data about a new kind of medicine, right? So the medicines that we're largely going to talk about today are medicines that belong to the class of medicines called JAK inhibitors or Janus kinase inhibitors, right? And we're familiar with these. We've heard these words before.

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Olumiant. Litfulo, Leqselvi, right? Those are the approved medicines, the approved JAK inhibitors for alopecia areata. What's again, what's exciting is that at the meeting, I had the privilege of presenting this data for an investigational medicine that's not a JAK inhibitor and super important here.

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This is investigational. This is not a medicine that you can go to your doctor's office tomorrow and say, Oh, I want to try that one. Nope. It doesn't exist in the world yet, meaning it's not commercially available. In an early clinical trial in alopecia areata, there was evidence of effectiveness, and there is a bigger clinical trial coming in the next few months of this medicine.

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Now on the right, you see the box that says Brave AA Peds. Efficacy and safety of Baricitinib among adolescents with severe alopecia areata. Many of you will know that we have presently, of the three medicines that are approved, Olumiant, which is Baricitinib, Litfulo, which is Ritlicitinib, and Leqselvi, which is Duruxolitinib, that only one of these -- Litfulo or ritlicitinib-- is approved in adolescence.

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So approved for people between the ages of 12 and 17. Here in this presentation, we saw the results of baricitinib or Olumiant is the brand name, treatment of adolescence. So medicine that is presently approved in adults. We saw data for it in adolescence, and it's really great data, a lot of people in that age group of 12 to 17 successfully that grow their hair.

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over 36 weeks of treatment and we'll look forward in the next handful of months to the data out to week 52. And I'm certain that 40 percent of adolescents successfully regrowing their hair is going to grow to higher numbers. So really amazing. It means that on the horizon, we're going to have not one, but two treatments for adolescents.

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with this condition. All right, let's move on. Time to grow hair. This is critically important, and one of the things that I really love and admire about the community of people with alopecia areata and their families is that you all are very educated about Your condition. And as I started, you're often going to know more than the people you are going to see and seek treatment from.

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And this part of the talk is critically important. The reason I know this is true is because I see many people with alopecia areata, and people often come to see me, and they say, Oh I took. That medicine, one of the approved JAK inhibitors. Oh, I took a lit full. Oh, I took aluminum. I took it for three months, but it didn't work.

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And so now I'm here three months. No. We can't make a treatment about. Success never ever before six months and probably not before nine to 12 months. And so I'm going to show the data. So before we get to it, I just want to briefly recap what is happening in alopecia areata and how do we stop alopecia areata?

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How do we. grow hair. So this is a little cartoon. Don't pay too close of attention, but up above is the hair follicle. Down below is an immune cell over here. We're looking closely at the bottom of the hair follicle with this crowd of immune cells attacking it. And the whole idea is that interactions between.

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The hair follicle or the hair follicle cell and immune cells is what leads to hair loss. Therefore, how are we going to stop alopecia areata? How are we going to regrow hair? We want to block these interactions. And you'll see in the center of the slide with those red arrows, there's this feedback loop that happens driven by certain molecules.

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And again, the details are not critical, but just to say that we have a reasonably good idea what these molecules are and what these interactions are between hair follicle cells and immune cells that lead to hair loss.

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So here you see with the two big Xs, those are where JAK inhibitors interrupt this feedback loop. The point of showing this slide is we have to first, it's just to show, we have to first block inflammation around hair follicles. We have to first block the immune system attacking hair follicles before this hair follicle over here can do what it was born to do, which is grow a hair.

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It takes time to block that inflammation. It doesn't happen in a day. It doesn't happen in a week. It probably doesn't happen in three or four weeks. And regrowing hair takes many weeks. Many weeks, not two weeks, not three weeks, not four weeks. It takes many weeks. And here we see the very first person in whom this was ever done.

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This was my patient with psoriasis and severe alopecia areata. I gave him this medicine, tofacitinib. Of course, back then, I knew not at all what I was doing. This was the very first person ever treated. And we see five months he had his hair. Remember something, and by the way, Kyle here, he grew hair exceptionally fast.

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So just to be clear, he grew hair exceptionally fast. But my point where I started was that dermatologists. Are most familiar with the treatment of psoriasis. They're more familiar with the treatment of eczema. And what we have learned in a way from treatment of those conditions is that they get better fast.

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They get better in a month. They get better in two months or three months. This person, and I'm telling you, hear my words. This person, Kyle, on the screen, he grew hair exceptionally fast, and it took five months.

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What's the data? That we have right so that you're not just hearing my words. This takes many months. But if you look here, this is data from the lit fulo clinical trials. And what they did was they took all the patients treated with the approved dose of 50 milligrams once daily, and they looked at the different patterns of regrowth, the different treatments that were available.

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And they see regrowth across the people who succeeded and then of course they also many people do not succeed and so we see those people here. But let's just look at this to understand how long it often takes to grow hair. At the very top where all of the lines start. We have people with no hair on their head.

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And then as we move down, as those lines descend towards the bottom, that is people achieving no hair loss, right? If you get all the way to the bottom, you have no hair loss. So at the top, everybody's starting with no hair. At the bottom, they end up with a full head or near complete scalp hair regrowth.

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Look at the axis at the bottom. These are months. So six months, 12 months. 18 months. And look here, when you look at that red line, only 18 percent of people will achieve complete regrowth of hair in six months or less. Only 18 percent of people. Look at the orange line, another 17 percent of people take nine months to regrow their hair.

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And then look At the next line up above, the purple line, it gets a little bit confused and mixed with the other lines, but that 11 percent of people, they take longer than 12 months to achieve a near complete or complete amount of scalp hair. So do you see it takes, when I say Many months.

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Many months. It is not the most common person who will regrow their hair in the first six months. The majority of people who are going to succeed. will not regrow their scalp hair for six to 12 months or longer. And so it's really important. You have to be patient. Your dermatologist needs to be patient.

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You cannot go back to the dermatologist in three months and say, Oh gosh, I've only, look. Look at this. I don't have all of my hair. I want to switch. Terrible idea. We shouldn't be making decisions, any treatment decisions, about switching before 6 to 9 months at a minimum. And if you are growing hair, as we're about to see in the next slide, if you are growing hair at 3 months or 6 months, You keep going.

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You don't say, Oh, I want to do it faster. I'm going to switch to another medicine because I have a friend, or I read on a blog that somebody did it like this or that. Here you see the truth. This is Data across many people.

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So now, I love, because that graph, it illustrates the data in my mind beautifully, but here, the photos tell the whole story. Look at this. Remember, we just talked about people who respond very quickly, relative or relatively quickly. in the first six months. Then we talked about people who regrow between six months and one year.

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And then we talked about yet a third group of people who regrow after one year. It's illustrated here. These are people who were treated with baricitinib or Olumiant and this is somebody who had a lot of hair at week 12. And right, I get it, everybody who's here, I get it, right? You start taking a medicine today to regrow your hair, right?

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For you, you never wanted to lose it. You can't get it back quickly enough. And so we would all like For everybody who undertakes treatment to be this person at the top at week 12 It's almost all there at week 36. Holy cow. Look, a complete head of air but Remember I said that's maybe I don't know hard to say maybe of everybody who succeeds That might be 30 percent of people it's not the majority of people then you look here In this second row, this person comes in at week 12, there's not a hair, not one hair has grown.

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But then look over here at week 36, month 9, a lot of hair is there, right? Most of the hair has come back. But really important, look at week 12, there's not a hair. And now let's take that third group, the late responders. At week 12, there is not a hair. At week 36. Over here. There's a lot of fuzz at week 36 at month nine.

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There's a lot of fuzz, not the hair we're looking for fuzz. But then look here, 16 weeks later, four months later at one year, there's nearly a full head of hair. Please, everyone, be patient. Do not insist that at three months, it's all there. Don't insist at month six that it's all there.

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This unfortunately takes a lot of patience.

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And this is a little bit of help, I think. What we're looking for is a 30 percent change from baseline. So right, so you take somebody who has no hair and you get them down to 70 percent loss. So 100 percent loss to 70 percent loss. That change, that 30 percent improvement very frequently marks future success, future complete or near complete.

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It's not a perfect marker or not a perfect factor to predict future success, but it's really good at it. So again, we're looking for hair growth over many months. You have to be patient. One of the things that I personally very much to do And I'm a huge advocate for it when I speak to my colleagues in dermatology is the use or the combination of oral minoxidil together with JAK inhibitors.

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I think, I don't have a lot of evidence for this, but I'm 90 percent sure that what the addition of oral minoxidil to a JAK inhibitor does is it shifts the time in the direction that we want. That maybe that person who might have taken 6 months or 9 months to respond will do it in 3 or 6 months.

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And similarly that person that might have taken a year to respond might respond in 9 months. And so I'm hopeful that we're going to learn over time that it both makes it happen faster but also increases the proportion of people who succeed. So if you can, if you feel comfortable, advocate for use of oral minoxidil in your treatment as long as it is thought to be safe for you.

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Okay, so now, dose of medication. So here, this is only relevant to one of the approved medicines. Ritlicitinib or Litfulo has one dose, 50 mg. Leqselvi, which is not commercially available, but which is still in clinical trials, but the only people who are taking it are people who are in clinical trials, that has one dose, 8 mg twice a day.

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But the medicine Baricitinib or Olumiant, has two doses, two milligrams and four milligrams a day, and it's really important. We should all dermatologists are going to have a slightly different approach to use of those two doses. Even the instructions in the package insert says that if you have no hair at the start of treatment.

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Or almost no hair. So for me, that's somebody who's like 80 to a hundred percent scalp hair loss. That person should start with four milligrams, not two. They should start with the four milligram dose, and then people who have hair. So now let's say 50 to 70 or 80% scalp hair loss at the start of treatment.

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Many of those people will actually do very well starting at two milligrams. But the point is. Here, I just want everybody to see that dark green line at the top, that's the proportion of people achieving near complete or complete scalp hair regrowth during treatment. The two milligram dose is shown in light green.

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Look, literally almost twice as many people succeed when treated with the four milligram dose. And so my point is, If you undertake treatment, if you initiate treatment at the two milligram dose, and you are not having regrowth over the first, say, three months, then that's an appropriate time to elevate or escalate treatment from the 2mg dose to the 4mg dose.

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Alright? When there are more than one dose, then we have the ability to do better with the higher dose. And, unfortunately, many people need to advocate for that dose change. We now have data, again, from the AAD meeting that I was just at, showing that too often, people are not appropriately dose switched.

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And so let's again, unfortunately, many of you are going to have to advocate for yourselves in treatment. And so just remember with baricitinib or Olumiant, there are two doses. If you are not doing well with one advocate early for switching to the higher dose.

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So now very briefly, but very importantly, eyebrows, eyelashes, and scalp hair may respond differently to treatment. This is a really important point because very frequently when people have severe alopecia areata, there's loss of scalp hair. There's loss of eyebrows. There's loss of eyelashes.

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In men there's loss of facial hair. And it's very easy to think, Oh If I'm taking a pill that grows hair, then I'm going to get my scalp hair back, my eyebrows, my eyelashes, my facial hair, I'm going to get it all back at once. Not true. We're not going to really dive deep into the data here because it's just a bunch of graphs, but these are representative images of people from my clinic to help illustrate that holy cow, Now, responses can vary considerably.

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Very fortunately, and I want to be clear here, fortunately, I would say most people who have no scalp hair, no eyebrows and no eyelashes at the start of treatment, ah, most of them will get it all back. All three. But they don't always regrow at the same time. And sometimes. One or two of those areas responds and the other does not respond that well.

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So all four of these people started with no hair. This person in the lower right-hand corner, she regrew eyebrows, eyelashes, and scalp hair. The young man here in the upper right-hand corner, he re grew eyebrows and eyelashes and ultimately facial hair, but not scalp. This person in the middle, Regrew eyebrows and facial hair or beard, but not eyelashes and very little on the scalp.

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And then this person over here, regrew scalp and eyelashes, but very few eyebrows. So it's just to say, and again. There is not a rule here, but it's to say take a deep breath and undertake treatment and try as much as you can to be patient, to see what happens. Anybody who says, oh, I can tell you what's going to happen for you.

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They don't know. They don't know. You only know when you get there.

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All right. So now what happens when treatment is stopped? A really important. Question, and again, expectation of treatment. This for people who have seen me speak before here, this may be a familiar slide, but it's really important data. This is showing the proportion of people who maintained complete or near complete scalp hair regrowth in the clinical trial of Baricitinib, or Olumiant, and the reason for showing this data and not data from another clinical trial is this is the only clinical trial that has shown us this data.

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So you see, what happened was that at week 52 in the clinical trial, they took everybody who had regrown their hair, taking the 4mg dose or the 2mg dose, and half of the people continued on the dose that they regrew hair with. And half of the people, the medicine was taken away. Okay? Stay on treatment after a year, or take away treatment.

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And what do you see? That people, and we're going to come back to this in a minute, the vast majority of people who re grew hair, at one year, the vast majority of them, when they stay on the dose that they were taking, they maintain hair regrowth. Then these people here, the medicine was taken away.

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It was taken away in a year. And look at what happens. After another year. And then at two years, only 80 percent of them kept the hair that they regrew. And we learned a really important lesson. And it's one that I could have told you just from treating a hundred people and watching what happens when we make the wrong dose change or when people stop medicine for too long for some reason or another.

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But, this is really good data. It's really systematic and we know now that stopping treatment will lead to a recurrence of hair loss in 80 percent or more of people. So now let's look and focus a little bit more on the top. Another really important question that arises is if I regrew my hair will I ever have flares?

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Will I, does it mean if it works that I never have a spot again? Or might some people have a little bit of activity from time to time? The answer is yes, people will have some activity from time to time. Not everybody. There are some people who regrow and they don't develop another spot. But I would say many people, maybe a third or more of people, will have a little bit of activity.

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That might be one or two spots a year. And then there are some people who just, they bounce around more than a spot or two, but they'll even bounce have periods where they have. 15 percent scalp hair loss, and then we have to do something, maybe do injections, maybe put steroid on the skin, maybe in those people add oral minoxidil to get them back under control.

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And so my point is, it's not common for people to have big flares once they achieve treatment success, but it's not exceedingly rare. And so we have to be thoughtful about what to do for those flares, what to do to control that little bit of activity. But just know you're not alone if that is an experience that you've had.

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So again, stopping treatment will lead to disease flare in the vast majority, but not all of patients there. So what's neat is there are some patients who can come off and they stay clear. They say free of alopecia areata for a period of time, whether it's one year, two years or more.

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Getting close to the end here. What happens when the medication dose is decreased? Another really important question, right? Because sometimes people just want to try to get by on a lower dose. Sometimes somebody has a side effect. Side effects are really rare, but sometimes people have a side effect, and so we want to decrease the dose.

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This is what happens when somebody has achieved regrowth, and then the dose is lowered.

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So again, data from the baricitinib or Olumiant clinical trials, again, it's what we saw in the previous slide. When you take people in the clinical trial who had regrown their hair at one year, taking the four-milligram dose, and you continued some of them on the four milligram dose and you changed the other people to the two milligram dose, what happens?

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You start to see again. Up at the top, a 100 percent of people have all their hair. So as that line decreases, that means that people are flaring. And not a little bit, but flaring a lot. Losing a lot of hair. And what you see here is that 4 weeks, 8 weeks, 12 weeks, after that very quick change from 4 to 2 milligrams, many people, by the way here not most, but many people start losing hair.

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Some people don't start losing their hair until a year later. But the point is, about half of people who regrow their hair on four milligrams and switch to two very quickly, switch from four to two, about half of them will lose their hair over a, or start to lose hair significantly over the next year.

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And so for me, what we learn from this is that sudden big dose decreases will often lead to disease flare. So for me and my practice, I really try as much as I can. If you succeed at two milligrams, please stay on two milligrams. If you succeed at four milligrams of baricitinib, if you succeed with 50 milligrams of Litfulo, please stay on the medicine.

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Stay on that dose. We don't need to change it. However, again, this is not ever, my decision. This is a decision made between me and my patients. For somebody who is having side effects or just wants to see if they can get by with less medicine, the idea is we change the dose very slowly. So not four to two in the case of Olumiant, it would look more four milligrams, five days a week, two milligrams, two days a week.

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And you would do that for four months or five months or six months before considering another dose decrease. With Litfulo, that would look like taking away one pill. A week and doing that dose for four or five or six months before considering taking away a second dose. Again, super small changes in dose over four to six months before ever considering another dose change.

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And now the very last. Part failure of one treatment does not predict failure of another one and here just really Important there's no data to show we don't have that kind of data in clinical trials But I can tell you Because I do this, I've done this in hundreds of people. My wife, Britt Craiglow, has done this in tens or hundreds of pediatric patients.

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We've learned that when somebody does not succeed with one of the JAK inhibitors, or, for instance, somebody decides to try Dupixent. And let's say some people succeed with Dupixent, but let's just imagine somebody, they do not succeed with Dupixent. In fact, I just got photos from a family in Denver, just yesterday.

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They had wanted to try Dupixent in their 13-year-old. We did it. We did it first nine months, again, getting back to that idea. You have to give treatment a long time before you can make a decision. The child did Dupixent for nine months, maybe even a year. Didn't grow hair. We switched to a JAK inhibitor, and they sent me photos.

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Eight weeks in, there's hair growing. Not a full head of hair, but there's hair growing. And so it highlights really beautifully that failure of one medicine does not predict failure of another one. Even the JAK inhibitors, which are all in the same family. Failure of one does not predict failure of another one.

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Now you want to be really thoughtful about the second one. You want to do everything you can to optimize success, add oral minoxidil, do topicals, right? You want, you, you want for your dermatologist to be creative. But the point is, I have people, I have one fellow in my clinic who has taken three JAK inhibitors.

[00:43:42]

For a period of nine to twelve months, each one. Imagine his persistence. No success. He has all of his hair today. With a fourth JAK inhibitor. Again, we have a, we've come so far, but we have a long ways to go, right? We would love if we could take a biopsy or do a blood test and say, Oh, you know what? The right one for you is this one.

[00:44:09]

But we're a long ways from that. That's not gonna happen next year, the year after, or the year after that. We're a long ways from that. But these are the things to remember.

[00:44:22]

And so this is everything that we've covered. Everything. A lot. And we could have spent three hours talking about it all, and I could have gone into more detail, but we hit the highlights. For me, for all of you, I know it's hard. I've watched so many people go through it and I don't know, as much as any of you who are going through it, how awful it is.

[00:44:48]

But I think I get it. And it's easy for me to say it's hard to live through it, but you just have to be patient. Don't start a medicine and expect in three months. I don't even see my patients back. People who come to see me and I start them on a medicine today. I say, are you going to come back in six months?

[00:45:09]

In fact, just today, my nurse was speaking to somebody who started medicine six weeks ago. And they're like, I don't, I guess I forgot why am I not coming back to see Dr. King yet? And she said, Oh, everybody comes back in six months because unless you're having a side effect, there's nothing that we can't make a decision before month six about anything.

[00:45:31]

And so Please be patient. Give the medicine six or nine months. Sometimes we even need a year. Don't switch because you read on the internet that somebody did something or they did this other thing and it worked. And so you're certain that's going to be the thing for you. No, nobody has that crystal ball.

[00:45:52]

Once you start down a road, keep going. Advocate as much as you can to take oral minoxidil together with a JAK inhibitor. If somebody puts you on the two milligram dose of Olumiant and you're not growing hair after three months, ask for the four. And just recognize that there's a lot of nuance here.

[00:46:12]

Eyebrows, eyelashes, and scalp hair don't always grow. They don't always grow together. Sometimes they grow eventually, but again, not at the same time. And with that, I'm happy to take questions and answers or questions. Sorry.

LISA ANDERSON, PHD:

Thank you, Dr. King. That was really informative talk. I don't know if you want to stop sharing your slides.

[00:46:35]

Everybody could see you better. There you are. Thank you so much. We have like almost 500 people on here right now. So lots of questions coming in. It's pretty amazing. One thing I want to ask and a question that came in what questions should be asked to determine if your dermatologist is familiar with JAK inhibitors.

[00:46:55]

And I think that goes along with advocating for yourself. Do you have tips, how do you broach these kinds of conversations with, your doctor.

DR. BRETT KING:

I wish I wish I had the, the perfect answer for you. It's such a good question. And, I think you just, you, I would just say to ask, the difficult thing is you take three months sometimes to get in to see somebody and then you're sitting there and you Ask the question, have you done this more than once?

[00:47:27]

Have you done it once? How familiar are you with these medicines? And right, you may very well get a, oh, I don't I haven't done this before. But if they're willing to try, that's huge. And for that visit, again, I commented on this earlier, it's, you all know, honestly, a lot more than the people that you're going to see.

[00:47:57]

And so come equipped with information, come equipped, say, I, I've heard that oral minoxidil plus a JAK inhibitor is better. Can we also do that? You have to advocate for yourself. And I think Lisa, you have right at NAAF, you have a doctor finder. And it's a little bit. Relevant to this question, is there is, do we have some tools?

[00:48:22]

And I think NAAF has one to at least help begin to guide all of you to find somebody who can help.

LISA ANDERSON, PHD:

Yes, we thanks for mentioning that and I'll share a slide. After we conclude that has a QR code for people to reach the doc to find the doctor finder on our website. Here's a question and I'm not sure that we actually, you actually talked about this.

[00:48:43]

Does it matter if I've been bald for three years? So length of time before starting treatment?

DR. BRETT KING:

Oh, I love it. I love it. And I didn't go into all the, there's so much that we could talk about. It's just, we have so limited time. So no, absolutely. If you have. Not had hair for three years.

[00:49:02]

This is the time. Go get a JAK inhibitor. This is the time. Four years. It's okay. Five years is okay. Six years is okay. Seven years is okay. But just to be clear, every year, after probably four years of having no hair, every year decreases one's chances of success. A little bit. Not a lot, but decreases. Your chances of success a little bit and so really, I hope very much and my colleagues who do this a lot.

[00:49:40]

We hope so much that, in five years, there won't be anybody who has not had hair for five years because everybody when this happens, they're going to go, they're going to see somebody who knows somebody who cares and somebody who's going to treat them

[00:49:58]

regrow hair in everybody who wants it.

LISA ANDERSON, PHD:

Okay. Thank you. Someone's asking about switching. If you're switching JAK inhibitors, does the timeline start over? So my son switched from Litfulo to Olumiant after nine months. Do any of the effects of Litfulo will carry over or is he starting from week zero?

[00:50:25]

So it's hard to know if this person has had hair regrowth or not.

DR. BRETT KING:

Yeah, it's a great question. I think exactly as you point out Lisa, it has everything to do with is Right. So somebody I recently encountered had regrown their hair with one of the JAK inhibitors, but their insurance was saying, Nope, we don't do that one anymore.

[00:50:51]

You have to switch to the other one. There's a lot of anxiety when that happens. I would say that if there was successful treatment, complete or near complete scalp hair regrowth with one. Then switching,

[00:51:12]

is likely to succeed, but we don't have great data on that yet. I would say likely, but not definitely to succeed. And it may be that at some point there will be, for some people they will need to keep going with the one that they re-grew hair with because the other one's just not as good for them.

LISA ANDERSON, PHD:

[00:51:34]

Here's another question about why does it take so long for the drugs to work since if the drug is blocking a pathway, why does it take so long? Does it only bind at certain times? Can you, do you have insight into why the process takes so long? Is it partly how the way the hair grows or it is that the, we think.

DR. BRETT KING:

[00:51:55]

And this is all speculation, but we think that the inflammation, those immune cells that I showed in that early picture, those immune, those little circles surrounding the hair follicle, the root of the hair follicle, those are really stuck there. They don't move away easily. And we need, those cells need to see medicine, not for a day, not for two days.

[00:52:21]

They need to see medicine for weeks before that crowding, that crowd of cells disperses. And then remember the hair follicle has been under attack. It's not in, it's not ready to go. It has to reset and then grow a hair. And so it. It takes time. And by the way, I really, I'm somebody who believes even as treatments get better, I don't necessarily know that we're going to get faster.

[00:52:52]

Better just means more people will succeed. But I think that this is just inherently a process that takes many months. It's not a failure of our treatments.

LISA ANDERSON, PHD:

Another question. Thank you, Dr. King, for all this information. Do you think adding minoxidil late in the JAK inhibitor treatment? Like after eight months with only fuzz hair, would that still, we can still get a benefit?

DR. BRETT KING:

[00:53:18]

Please. Everybody, it's just, and again some dermatologists are going to say, no, I just want to use the JAK inhibitor first. And then we can think, whatever, down the road at month six we can think about adding something else, like oral minoxidil. That's fine. We're all going to have our own ways of wanting to proceed.

[00:53:38]

However, it's never too late. If minoxidil is, right and safe for somebody, it, if it's added at six months or nine months, absolutely. So when somebody comes to see me and they've been on a medicine for nine months and they've only grown fuzz like this person, like the question, peach fuzz or a lot of fuzz.

[00:54:02]

Of course I would have rathered for nine months to have been on JAK inhibitor plus minoxidil, but absolutely that's the right time. It's don't give up for sure. Don't throw away the last nine months, add oral minoxidil, optimize the dose. Your dermatologist needs to know how to do that, but hopefully they can optimize the dose and then give it another six months for sure.

LISA ANDERSON, PHD:

[00:54:27]

It's a great question. There are a couple of questions about shedding and do JAK inhibitors stop the shedding and, or when you're looking at how long it might take to regrow your hair is shedding part of that time period.

DR. BRETT KING:

So undertaking treatment. If you are in the middle of losing, just because you're starting treatment does not mean that you will not continue to lose.

[00:54:57]

Lisa, is that the question?

DR. BRETT KING:

If somebody two weeks ago, I met a young woman in clinic who probably had a 70 percent loss. And it all started three or four weeks before. Woke up with a spot and just Literally day after day more and more loss and everywhere around, the 30 percent of hair that she still had.

[00:55:23]

I pulled and it came out very easily. I said, I think I have a crystal ball here. And then the next four weeks you're going to lose all of your hair, even though you're undertaking treatment today, you're going to lose because once those hair follicles, are touched by the immune system. They're gonna fall out.

[00:55:47]

But they don't fall out tomorrow. They fall out in weeks. Maybe even six weeks. Undertaking treatment today, you may still see hair loss continue for the next four or six weeks. Because the ball's rolling. And a medicine, no medicine, can take that hair that's in a sense All but started to fall out and move it back in time and anchor it again in the skin.

LISA ANDERSON, PHD:

[00:56:22]

Are you okay if I just do two or three more questions?

DR. BRETT KING:

I'm happy to stay here for as long as we can.

LISA ANDERSON, PHD:

Okay, great. Here's another question. Is there a health benefit to calming down the immune response and doing this treatment aside from hair regrowth?

DR. BRETT KING:

Oh boy, that's a really provocative question.

[00:56:40]

I love that. That's a question for, people at the meeting I was just at. We, we love to talk about, what are the other things that might be associated with that. with any condition and by treating any condition successfully, might we improve somebody's overall health, right?

[00:57:03]

There's all this in medicine. These days, we'd love to talk about systemic inflammation. And the truth is, we don't know. And I would certainly never advocate to Anybody who came to see me, I would never say unless somebody had right. Recently I met a man who has ulcerative colitis. He has uveitis inflammation in his eyes.

[00:57:28]

He has no hair. He has a rash, something in between psoriasis and eczema. And for him a JAK inhibitor is like the most amazing thought of a medicine because a JAK inhibitor might fix his skin, grow his hair, fix his eyes, and fix his intestines, but I would never tell somebody who just had alopecia areata, oh, by the way, you should take this medicine, you should take a JAK inhibitor to grow your hair, but because I think we're also going to help you live longer or help you live healthier.

[00:58:10]

It's just, that's just, we just don't know.

LISA ANDERSON:

, PHD A question on topical medications. Are there topical medication, drugs that are being researched to see if they might be effective? Even just to preserve hair that has regrown while on one of the JAK inhibitors that you talked about.

DR. BRETT KING:

Yeah, it's a, it's, dermatologists love to put stuff on skin.

[00:58:34]

And so we have a long history of doing that. We have A little bit of data, I would actually say enough data for topical JAK inhibitors to say that topical JAK inhibitors don't grow hair. Your question is a little bit different, right? Your question is, so I took one of these oral medicines, I re-grew hair and I'm imagining that sort of somewhere in your question is, could I stop the oral medicine and just rub something on my head in order to preserve it?

[00:59:14]

And. I think that the answer is no, of course, I don't know that for sure, but I think of preserving as the where we get to after something works to grow, right? And so I don't think that we are at a place yet where I could ever tell somebody, Oh, now that you have it, use this to hold it.

[00:59:42]

I think that if you needed medicine to suppress the inflammation that caused hair loss, I think that you probably need to take that medicine to continue to suppress the inflammation that might make hair loss recur. The one thing quickly there is, I sometimes wonder, it's a little bit of a variation of the question that was just asked.

[01:00:09]

I sometimes wonder if oral minoxidil in that person in that person who just says, I just don't want to keep taking. the oral JAK inhibitor. I want to see if I can come off of it. For that person, I would 100 percent of the time say, okay let's be sure that oral minoxidil is optimized in the hopes that we might turn 20 percent of people who come off the medicine and keep their hair.

[01:00:36]

Maybe we turn 20 percent into 40 percent by doing it like that.

LISA ANDERSON, PHD:

And when you say optimized, what do you mean by that?

DR. BRETT KING:

Oral Minoxidil, I was part of the New York Times article two and a half years ago that was published show or that was printed suggesting that oral minoxidil is probably a better medicine than most for what I have, male pattern hair loss.

[01:01:06]

That article led to I think, a lot of use of oral minoxidil, which I'm quite excited about that dermatologists are reaching for it. But too often, people are given a tiny dose, a homeopathic dose. The, it, minoxidil comes as a two and a half milligram tablet and a ten milligram tablet.

[01:01:27]

So many people come to me and their dermatologist has them taking 625 milligrams, literally a quarter of that two and a half milligram dose. I'm not sure that just taking a deep inhale over the bottle isn't equivalent to swallowing a quarter of a pill a day. And so when I say optimized, I’m talking a dose that's more likely to work, two and a half, five, maybe even ten milligrams.

[01:01:54]

And again, it differs a little bit from females, in males and females. But the point is, taking a real dose of it.

LISA:

ANDERSON, PHD Okay, thank you. I have at least two more. This is a more practical question. Does wearing a wig that's bonded to the scalp impede hair growth? So if someone's You know, wearing still wants to camouflage while they're waiting for their hair to regrow.

DR. BRETT KING:

[01:02:19]

Can they wear a wig that's bonded to the scalp or what are the thinking on that? Yeah, no it's a great question. I glued. No because literally every time it's removed, it's literally like waxing. The skin, right? You're taking these, hairs that are starting to grow and you're yanking them out.

[01:02:43]

And so that makes me very nervous. Anything literally, glued or thoroughly stuck makes me nervous. But there are ways to, and again, I'm no expert in wigs but there are ways to get them onto the scalp without that glue for the person who does, for whatever reason need the glue, I would say at least minimize the contact points.

[01:03:18]

Between the wig and the scalp, right? So not bonded from here continuously from here to here because literally I've seen people come in doing that. And the only hair they're missing is in that area of tight bonding. And so I would just say, minimize the contact points where the bonding happens, right?

LISA ANDERSON, PHD:

[01:03:44]

That sounds good. This person wrote, if a dermatologist needs more information, is their best course, I think they mean more information about treatment and is their best course of action to contact a dermatologist. The drug companies, or can they contact you or someone at AAD? So I thought, maybe we do have health care providers listening to this webinar or patients want to talk to their dermatologist about where to get more information.

DR. BRETT KING:

[01:04:11]

It's such an important question. Honestly, Lisa, I think in some ways, maybe the best place to go is to come to one of these NAAF webinars, of course, they're not all relevant to that specific scenario, but right, it's, I've done one and I'm sure others have spoken during these NAAF webinars.

[01:04:35]

And the truth is, while I think that these are, amazing, guides or kind of frameworks for the community, I think right? Why can't they be utilized by a dermatologist? I just gave, really the ABCs of expectations of treatment. If a dermatologist could write those down and sort them out, they can take that into clinic.

[01:04:58]

So it's a great question and I wish that there were a better place for that person to go. But, We run around, we educate. I do. My wife does. Mary Ann Sena does. Natasha Mozankovska does. There are a handful of us around the U. S. who are at the podium, as much as our lives will permit, talking about this.

[01:05:19]

So the information's out there.

LISA ANDERSON, PHD:

Thank you. We're glad you're out there at the podium and talking like this. Someone asked, we didn't we didn't, this wasn't a talk about side effects or. Or, that's another. I don't know if you want to touch on that. We have other webinars on the NAAF website that I can point people to where there's where there's been more conversation.

[01:05:41]

Someone's asking about long term effects of using a JAK inhibitor for life. What do we know? What would you?

DR. BRETT KING:

Yeah, these are important questions. I, we just, I would just like to say really fast and I'm not avoiding the question, we'll get there.

[01:05:58]

People often will say, often, I think always, people will say, when we're in my clinic talking and about undertaking treatment, initiating treatment, they'll say but what do we do in a year? And, I Be here now this is where we are today and let's be here and let's address one year in one year, but so much can happen over those 52 weeks.

[01:06:27]

Let's not try to navigate every possibility. Let's see what. your path is from here to there. And then in a year, both of us are going to have a new perspective. And we'll address it then. That said, I do think that thinking about treatment. is that it's very likely to, for most people, again, who have severe 50 to a hundred percent loss, right?

[01:07:00]

And that's the data that I presented earlier, right? The data that we have suggests that most people will need to stay on treatment in order to keep their hair. The reason why I don't want to think too far ahead is it's actually a shout out to the very first slides. Look at the AAD, four days ago, I was talking about a treatment, right?

[01:07:25]

It's totally conceivable that like we'll have completely different treatments in four years or five years, non JAK inhibitors, medicines that might not need to be taken forever. That might more durably impact disease. And so the data that we have. Which is imperfect, but the data that we have says you can take a JAK inhibitor.

[01:07:50]

For years and years and years and years safely, there's no data that we have that says that these medicines are dangerous in the short term or the long term It's not to say that there will not be a rare bad event We don't have a whole lot of data to support that but again what I really don't want And it's the person, the earlier question about, I haven't had hair in three years.

[01:08:23]

Am I still a candidate? Please, everybody here, whether you are 50 or 30 or 70, or you're the parent of an eight year old who has not had hair in three years. Don't wait. Please don't wait for the future. The data that we have says that every year after four brings lower likelihood of success. And don't wait for the future.

[01:09:02]

Don't wait for four years or five years to see if we have a non JAK inhibitor that blah, blah, blah, blah. No. No. Have your hair between now and then. And then let's wait for five years to see if you can switch. Or if that thing exists, but I just don't, one of the myths of dermatology, and again, it was nobody's fault, but we've always described alopecia areata as being a reversible form of hair loss.

[01:09:33]

We now have too much data that says if you've not had hair for years and years and years and years. that your chances of regrowing at least scalp hair diminishes dramatically. And we want everybody to have the opportunity. And so undertake treatment. And then let's think about the future in the future.

LISA ANDERSON, PHD:

[01:10:02]

I think that is a good place for us to stop. Great advice. And, everybody appreciates your work and sharing this valuable information.

DR. BRETT KING:

Really my pleasure. I, it's just, it really is amazing. It really is amazing how far we've come and we're gonna, we're gonna go all the way.

[01:10:22]

This community, it's such a strong community. NAAF is such an amazing focus of energy to support the community to elevate an already super intelligent and super engaged community but this is, it's activities like this where we come together and. We elevate each other and we're going to get there.

[01:10:49]

We're going to get all the way step by step and together. Excited. Thank you, Lisa. Thank you, NAAf. Thank you. We're at the beginning of this. We really are.

LISA ANDERSON, PHD:

All right. Thank you so much. Dr. King. I'm going to share my screen again and wrap up this webinar with a few slides. Okay. So thank you for being here.

[01:11:16]

And thank you to the audience for being here. We appreciate having you online with us. Don't forget to share your feedback on today's webinar and help us plan future presentations. There will be a link to a short survey that will pop up in your browser window at the end of the webinar and we really appreciate your feedback.

[01:11:35]

Now here's some information about the doctor finder that we talked about. Am I sharing? I think I'm sharing. Yeah, that the the Dr. Finder that Dr. King mentioned, because this is a question that frequently comes up. How do I find a dermatologist or healthcare provider who can help me treat my alopecia areata?

[01:11:52]

So NAAF has created a tool to help you. You can scan this QR code to get to the Dr. Finder on the NAAF website. The Dr. Finder lists board certified dermatologists in the U.S. with experience in treating alopecia areata. The listing also includes dermatology nurse practitioners and physician assistants. You can search the listings by state to find someone near you.

[01:12:14]

We regularly add new names to the doctor finder as we receive their permission to be included. So we hope this is helpful tool for you. Now, if you enjoy today's talk, please consider joining us in person at the annual NAAF conference. Dr. King will be there to speak along with other experts on alopecia areata and members of the alopecia areata community.

[01:12:35]

NAAF's 40th annual conference will be held in Chicago from June 26th to June 29th, and the conference is a great place to connect with the alopecia areata community. with educational programs, support sessions, research updates, and social activities for all ages, including a camp for children. Register soon to take advantage of the early bird registration rate, which is available until March 17th.

[01:13:00]

And you can scan the QR code here to learn more about the conference and to register. And please join us for our next webinar, which is going to be entitled Young Voices, Real Stories, Perspectives on Living with Alopecia Areata. In this webinar, young adults will take center stage to share their powerful personal journeys.

[01:13:22]

Through their impactful stories, they will explore the unique challenges they have faced, from navigating self image to overcoming societal perceptions, all while showcasing their resilience and strength. Our panelists will openly discuss the strategies and support systems that have empowered them to navigate living with alopecia areata.

[01:13:40]

They'll also discuss their toughest challenges and the invaluable lessons they've learned along the way, offering insight and practical advice for others on a similar path. Whether you're living with alopecia, supporting someone who is, or simply want to learn more. This webinar will offer a powerful conversation.

[01:13:58]

This webinar will take place on Thursday, April 17th at 7 p. m. Eastern and 4 p. m. Pacific, and the registration is now open. You can use this QR code to get to the registration page. And as, as you can tell, there's a lot happening at NAAF. If you want to keep up, we'd love to have you receive emails from NAAF.

[01:14:26]

You can use the QR code here to subscribe to our email list so that you can get regular updates on alopecia areata news and research, our monthly electronic newsletter, and notices about upcoming webinars and other programs. And NAAF offers a number of resources and programs for the Alopecia Areata community, including support groups, our youth mentor and legislative liaison programs, the doctor finder, clinical trial listings, as well as information about our conference.

[01:14:52]

So to learn more about NAAF and the resources we offer, please visit NAAF.org or email us at support at NAAF.org. This concludes today's webinar program. Thank you so much for joining us. We look forward to seeing you on the next webinar. Take care, everybody.