Pediatric alopecia areata and JAK inhibitors: Bridging the gap between evidence and practice

Alopecia areata (AA) is a chronic immune-mediated disorder characterized by nonscarring hair loss that frequently begins in childhood and is associated with substantial psychosocial burden. Therapeutic options for pediatric AA remain limited, particularly for patients with extensive or treatment-resistant disease. Janus kinase-inhibitors (JAKis) have emerged as promising targeted therapies that interrupt the JAK-STAT signaling pathway central to AA pathogenesis. Currently, ritlecitinib is the only U.S. Food and Drug Administration-approved JAKi for pediatric AA (≥12 years), leaving most JAKi use in children off-label. Despite this, emerging evidence and clinical experience demonstrate meaningful hair regrowth in pediatric patients treated with several JAKis, including abrocitinib, baricitinib, deuruxolitinib, ritlecitinib, ruxolitinib, tofacitinib, and upadacitinib, with generally favorable safety profiles. Additionally, evidence suggests that JAKis may be particularly beneficial in children with concomitant atopic or autoimmune disease and may also play a role in patients with elevated IgE levels and eosinophilia. Early-onset and severe disease may also warrant earlier consideration of systemic therapy. Limitations include heterogeneous outcome reporting between various reports and studies. Overall, this clinical review synthesizes current evidence and clinical experience to provide practical guidance on JAKi selection, dosing, safety monitoring, and key considerations for implementing these therapies in pediatric AA.