Severity Is About Impact, Not Just Hair Count
PAs Buchi Neita and Jennifer Connor open with a familiar tension: dermatology went from having nothing for alopecia areata to three FDA-approved JAK inhibitors, yet many clinicians remain hesitant to prescribe them. Their guest, Dr. Arash Mostaghimi, reframes the starting point of every visit — not the hair count, but how much the disease is affecting the person in front of you.
Mostaghimi stresses that alopecia areata is fundamentally a psychosocial disease. It rarely hurts or itches; instead, it erodes self-esteem and a patient's ability to present themselves to the world as they wish to be seen. He notes that some patients with no hair are perfectly happy and want no treatment, while others with minimal loss are profoundly affected — dropping out of school, refusing to get married, or avoiding presentations. He treats the impacted patient with minimal loss more aggressively than the unbothered patient with none.
He walks through the tools. The SALT score measures how much hair a patient has lost (SALT 100 = totally bald, SALT 0 = full hair). In trials, severe meant SALT over 50, and success meant SALT under 20. Insurers now use that same threshold, so Mostaghimi documents 'SALT greater than 50' for qualification and 'SALT less than 20 or full regrowth' for success, without agonizing over precise percentages. He also describes the AASC, which starts with SALT but lets you bump a moderate patient (roughly 20–49) up to severe for rapid loss, failure of therapy over six months, significant psychosocial impact, or facial hair involvement (eyebrows, eyelashes, beard).
The Same Paradigm Shift Dermatology Already Lived Through
Miranti draws the parallel to psoriasis, where clinicians once reserved systemics for patients with very high body surface area and now move to systemic therapy earlier for special sites and high psychosocial burden. Mostaghimi agrees alopecia areata is heading the same direction — but says the field is still in the 'early innings.'
He recalls that early biologics for psoriasis were reserved for erythrodermic-level involvement, and clinicians once worried far more about cancer risk than the data ultimately supported. As benefits are better understood and perceived risks shrink, the risk-benefit calculus shifts toward treating earlier. Connor shares the story of a teenager she treated with intralesional steroids before JAK inhibitors were approved — a boy whose SALT score was well under 50, but whose life visibly changed when his hair regrew, as witnessed by his father, also an alopecia areata patient.
The Three JAK Inhibitors — and Why Timing Matters
Mostaghimi reviews the three approved oral JAK inhibitors in order of approval: baricitinib (Olumiant), ritlecitinib (Litfulo), and deuruxolitinib (Leqselvi). His bottom line: 'the best JAK inhibitor for your patient is the one you can get that insurance will pay for.' All share a class black box warning.
Baricitinib is once daily, a JAK 1/2 inhibitor, and the oldest — with 10-plus years of safety history from rheumatoid arthritis use, which reassures patients. It comes in 4 mg and 2 mg doses; he considers the 2 mg dose underdosed and starts most patients at 4 mg, noting the only real difference is mild laboratory abnormalities, not clinical side effects. Ritlecitinib is once daily, 50 mg, a JAK 3/TEC inhibitor that is 'cleaner' on labs — no lipid monitoring needed — and is the only agent approved for ages 12 to 18, making it his go-to for adolescents. Deuruxolitinib is 8 mg twice daily (it does not work well once daily) and requires pretreatment genetic testing for a liver-metabolizing enzyme, which SunPharma will cover; only about 1–3% are poor metabolizers. He finds it may work faster and deeper, so he reaches for it when a patient has a hard deadline like a wedding or graduation.
Crucially, Mostaghimi says failing one JAK does not mean failing the class — unlike switching biologic classes in psoriasis, you can move from one JAK inhibitor to another in any order and may get a very different response. And he emphasizes the clock: the earlier you treat within roughly the first four years of the current episode, the better and faster the regrowth. Unlike psoriasis, waiting has consequences, so patients should err on the side of action.
The Conversation, the Side-Effect Worries, and a Message to Hesitant Prescribers
Mostaghimi shares his actual script and insists the counseling need not blow up a clinic schedule — he sees 22 patients in a half day with 15-minute new hair visits. He explains the JAK-STAT pathway, uses a garden metaphor for the delay between quieting inflammation and visible regrowth, and sets concrete calendar expectations (improvement by Thanksgiving, a decision by Valentine's Day). He is candid about the black box warning, explaining it stems from higher-dose tofacitinib in older, sicker RA populations, and frames JAK inhibitors as a relationship to 'date first,' not a lifelong marriage. He brings patients back in person at one month for labs and repeats most of the conversation, since patients rarely absorb it the first time.
For patients convinced every cold is a drug reaction, he never argues that it isn't the medication — that only creates a standoff. Instead, he says he's comfortable with the drug, that isn't a typical side effect he sees, and suggests pausing for a few days and getting worked up so nothing else is missed, then restarting later. On prognosis, the strongest positive predictors are a shorter current episode and more remaining hair at baseline; adolescents respond notably better, adding 20-plus percent to efficacy.
Older agents like methotrexate, cyclosporine, and azathioprine, he argues, should rarely be part of the arsenal given their weak efficacy, comparable risk, and the National Alopecia Areata Foundation’s move to remove them as step therapy. Miranti adds a caution about cumulative lifetime steroid exposure — systemic, intralesional, and even topical. To hesitant colleagues, Mostaghimi is blunt: comfort and safety are not the same thing, and if you won't prescribe JAK inhibitors for severe alopecia areata, it is your obligation to find someone who will. Start with a low-risk patient, pick one drug, phone a friend, and evolve — or medicine will pass you by.