Is baracitinib also an option for refractory lichen planopilaris and frontal fibrosing alopecia?

40 % of FFA and 14 % of LPP benefit from Baricitinib

Prior studies have suggested that targetting that JAK pathway may be relevant for the treatment of lichen planopilaris. A 2018 study by Yang and colleagues suggested that tofacitinib may have a role. Specifically, 8 of the 10 patients with refractory LPP benefitted. The LPP activity index (LPPAI) reduced from 6.22 to 3.08 after using tofacitinib. 4 patients were using the tofacitinib as the sole therapy (monotherapy) and 4 used it in combination with other treatments.

The use of baricitinib had not been studied and this was the purpose of the current study

Moussa et al, 2022

In a new study, authors set out to retrospectively reviewed the records of all LPP patients treated with baricitinib for at least 3 months. Disease activity was assessed using the Lichen Planopilaris Activity Index (LPPAI). According to the LPPAI, a score of 0 indicates no disease activity a score of 10 indicates maximal disease activity.

There were 12 patients with recalcitrant LPP in the study. 7 had classical LPP and 5 had FFA. The median age at diagnosis was 43 years (IQR 30.3-55.3) and the median disease duration was 7 years (IQR 3.3-12.0). The median baseline LPPAI score was 5.8 (IQR 4.7- 6.9). Baricitinib was commenced at a median dose of 3.4 mg and the dose was increased according to response. Concurrent treatments were used in all patients (Table II).

Baricitinib in LPP

Five out of 7 patients with classical LPP demonstrated an initial reduction in median LPPAI score of 2.8 (46.5%, p=0.043), but response was maintained only in 3 after a median duration of 6 months. In other words, a 6 months, 4 patients were non responders, 2 were partial and 1 was a good responder. None had the disease shut off. 2 patients with LPP did not respond to baricitinib at all and 2 lost response after showing some initial promise.

2 patients that had failed prior use tofacitinib were part of the study group. 1 responded initially and then lost response. 1 of the patients who used tofacitinib in the past did partially respond to baricitinib and maintained that same response at 6 months.

All in all 3 patients had a sustained response to baritininb at the 6 month mark. This was quite a significant response in 1 patient (14%) and a partial response in 2 patients (28.6%)

Baricitinib in LFFA

Three out of 5 patients with FFA demonstrated an initial reduction in median LPPAI score of 5.6 (83.8%; p=0.11) with response maintained in 2 of the 5 after a median duration of 6 months. Overall, the reduction in median LPPAI score was 1.2 (20.2%; p=0.012) and 1.3 (23.1%; p=0.063)  at the initial and follow up reviews respectively.

2 patients with FFA did not respond to baricitinib at all. These two patients had been treated with tofacitinib in the past and failed to respond to this medication as well .

All in all, just 2 of the 5 patients (40%) with FFA had a significant and maintained response to baricitinib at 6 months.

Conclusion

This is an interesting study and helpful study. it’s a small study so conclusions are limited.

a) 40 % of refractory FFA and 14 % of refractory LPP had a fairly nice response to baricitinib. It appears that baricitinib works only in a minority of FFA and a minority of LPP and is perhaps better in treating FFA than LPP. This was a small study and larger studies are needed.

b) Baricitinib may help some LPP patients who failed to respond to tofacitinib but only partially. only 1 of 2 patients with LPP who failed tofacitinib benefited from baricitinib. Patients who fail tofacitinib may be better candidates for other treatments rather than continued use of JAK inhibitors. This was a small study and larger studies are needed.

c) Baricitinib may not be a good option for FFA patients who failed to respond to tofacitinib. None of the two patients with FFA who failed tofacitinib benefited from baricitinib. Patients who fail tofacitinib may be better candidates for other treatments rather than continued use of JAK inhibitors. This was a small study and larger studies are needed.

REFERENCE

Moussa A et al. Treatment of lichen planopilaris with baricitinib: A retrospective study.J Am Acad Dermatol . 2022 Feb 21;S0190-9622(22)00338-3.

Plante J, Eason C, Snyder A, Elston D. Tofacitinib in the treatment of lichen planopilaris: A retrospective review. J Am Acad Dermatol. 2020 Nov;83(5):1487-1489. doi:

Yang et al. Tofacitinib for the treatment of lichen planopilaris: A case series. Dermatol Ther 2018 Nov;31(6):e12656.