The edition · Dermatology
Expert consensus puts oral JAK inhibitors first for severe alopecia areata
Thirty-one experts reached consensus that oral Janus kinase inhibitors are the primary long-term therapy for severe alopecia areata in adults, a new Good Practice Statement tells you to re-examine the diagnosis when atopic dermatitis fails to respond, and a Treg-expanding biologic cut eczema severity by 61%.
The edition in brief
A three-round Delphi process among 31 US alopecia areata experts, informed by systematic review, reached consensus on treating severe disease in adults. Oral Janus kinase inhibitors are the primary long-term therapy for all patients, with dupilumab an alternative where there is comorbid atopy. Supplemental options include oral and topical minoxidil, intralesional, oral and high-potency topical corticosteroids, and topical JAK inhibitors and prostaglandins with body-site-specific indications, alongside patient support resources. The recommendations explicitly exclude children, pregnancy, mild-to-moderate disease and patients with significant comorbidity. Separately, a multidisciplinary workgroup has issued a GRADE-based Good Practice Statement on adults with presumed atopic dermatitis that does not respond to optimised treatment, supporting diagnostic reassessment rather than further escalation. The workgroup is candid that direct evidence on workup strategies does not exist and the statement rests on indirect evidence and consensus. REZOLVE-AD, a phase 2b trial in 393 biologic-naive adults with moderate-to-severe atopic dermatitis, tested rezpegaldesleukin, an interleukin-2 receptor agonist that selectively expands regulatory T cells. All three dose groups met the primary endpoint, with EASI falling 61% on the highest dose against 31% on placebo, a treatment difference of 30 percentage points. Injection-site reactions occurred in 70% against 4%, almost all mild to moderate. A systematic review of 68 studies and 15,427 patients across five inflammatory skin diseases reports EASI-75 rates of 38-73% for oral JAK inhibitors in atopic dermatitis, with herpes zoster reactivation in 1-3%.
Consensus: oral JAK inhibitors are first-line for severe alopecia areata
For adults with severe alopecia areata, expert consensus now places oral Janus kinase inhibitors as primary long-term therapy, with dupilumab where there is comorbid atopy — though the recommendations exclude children, pregnancy and milder disease.
When atopic dermatitis will not respond, reconsider the diagnosis
A new Good Practice Statement advises re-examining the diagnosis in adults whose presumed atopic dermatitis fails optimised treatment, since misdiagnosis or a concomitant condition is a common reason for apparent resistance.
A regulatory T-cell-expanding biologic cut eczema severity by 61%
Rezpegaldesleukin, which expands regulatory T cells rather than blocking a cytokine, cut eczema severity by 61% against 31% on placebo in a phase 2b trial, at the cost of injection-site reactions in seven of ten patients.
JAK inhibitors across five skin diseases: what the pooled numbers show
JAK inhibitors are effective across five inflammatory skin diseases with response rates broadly between a third and three-quarters, but herpes zoster reactivation in 1-3% is frequent enough to raise vaccination before starting in older patients.
Refractory eczema is a diagnosis to re-open, not a dose to increase
Before escalating treatment in adult eczema that will not respond, re-open the diagnosis — biopsy and a careful contact history are the highest-yield steps, and immunosuppressing an unrecognised cutaneous lymphoma is the outcome to avoid.
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