Real-World Outcomes of Baricitinib and Ritlecitinib in Refractory Alopecia Areata: Response Predictors and Relapse After Discontinuation or Dose Reduction.

Baricitinib and ritlecitinib are newly approved systemic Janus kinase (JAK) inhibitors for severe, refractory alopecia areata (AA). Although clinical trials have demonstrated their efficacy, real-world evidence remains limited, particularly regarding predictors of response and outcomes following treatment interruption or dose tapering. To evaluate the real-world effectiveness and safety of baricitinib and ritlecitinib in adults with refractory AA, and to identify factors associated with treatment response and relapse. We retrospectively reviewed 65 adults with refractory AA treated at a tertiary center (baricitinib 4 mg/day, n = 50; ritlecitinib 50 mg/day, n = 15). Scalp regrowth was evaluated using the Severity of Alopecia Tool (SALT) up to Week 52, with response defined as SALT ≤ 20 (≥ 80% scalp coverage). Predictors of Week 36 response were assessed in the baricitinib cohort using multivariable logistic regression. Relapse outcomes after treatment discontinuation or dose reduction were documented with extended follow-up. Adverse events (AEs) were recorded. At Week 36, 42% of patients receiving baricitinib achieved SALT ≤ 20, comparable to the ritlecitinib group (41.7%). In the baricitinib cohort, disease duration < 2 years and baseline eyebrow loss (ClinRO score 3) independently predicted Week 36 response (p < 0.05). All four responders who discontinued baricitinib relapsed (mean 14.7 weeks). Among 13 patients who reduced the dose to 2 mg/day, relapse occurred in 6/12 evaluable cases (mean 24.2 weeks). Most AEs were mild, and no serious events occurred. Baricitinib demonstrated meaningful real-world efficacy, particularly in patients with shorter disease duration and baseline eyebrow involvement. Relapse was common after treatment cessation or dose tapering, supporting the need for close monitoring for approximately 3 months after discontinuation and at least 6 months following dose reduction. These findings may inform patient selection and long-term treatment planning, and highlight the importance of further prospective studies to optimize JAK inhibitor management in AA.