Treatment of Central Centrifugal Cicatricial Alopecia (CCCA) with Baricitinib

JAK Inhibitors for CCCA? A Closer Look at Baricitinib (Olumiant)

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Central centrifugal cicatricial alopecia (CCCA) is a lymphocytic scarring alopecia. The pathogenesis is not clear although it appears that a genetic predisposition together with external factors that lead to follicular injury may be involved. These factors may include heat and chemicals for a proportion of patients with CCCA.

A 2023 study by Roche et al suggested that STAT3 is activated in the perifollicular lymphocytes in patients with CCCA. These findings make it possible that drugs like JAK inhibitors that reduce STAT signaling in the skin can help CCCA.  

Workman and Kindred, 2023

I was interested to read a new report of a patient who had hair regrowth with use of a very short course of baricitinib. The patient was a 42 year old African American woman who presented to clinic with a 5 year history of hair loss along with itching and burning. Biopsies confirmed the diagnosis of CCCA.

She was treated with 40 mg oral doxycycline, 2.5 mg oral minoxidil, 0.1% topical halcinonide solution as needed and monthly triamcinolone acetonide injections.

Steroid injections helped control symptoms. However, it was noted that the patient’s disease repeatedly worsened when the injections were extended beyond once a month. She was tried on higher doses of doxycycline too but this caused intolerable gastrointestinal symptoms.

Two years after presentation, symptoms returned.

A decision was made to start off-label use of baricitinib 4 mg   and the patient was continued on monthly intralesional triamcinolone injections. The  topical halcinonide and the 40 mg of oral doxycycline were both stopped.

After 1 month, the symptoms resolved. After 2 months, regrowth of some of the hair was noted.

Patient with CCCA treated with baricitinib 4 mg. Shown here are the results at 2 months. Workman K and Kindred C. Hair regrowth in a patient with central centrifugal cicatricial alopecia after a 2-month trial of baricitinib. JAAD Case Rep. 2023 Jul 28:39:109-111. Used with creative commons license. Orientation of photos altered from original (side by side here and over top of each other in original)

Conclusion

This is an interesting study that positions JAK inhibitors as a possible treatment option for CCCA. I think we have to be careful about placing this too high on the list of options until more studies are done. But this is certainly a reasonable option.

It still is quite reasonable to consider steroid injections, doxycycline, oral and topical minoxidil as first line agents. But clearly topical 10 % metformin and JAK inhibitors are sitting right there as reasonable second line options.

Like all good studies, this study raises many many questions.

First, what would happen if baricitinib was extended for 2 more months? What about 6 or 8 months? Are the effects lost ? Do more improvements happen? How long of a treatment does one need? 6 months? 6 years? And what happens when the drug is stopped?

Are other JAK inhibitors also beneficial or is there someone about JAK1 and JAK 2 inhibition that baricitinib offers?

One wonders about topical JAK inhibitors as well. If we can achieve the same outcome with a topical JAK inhibitor rather than an oral JAK inhibitor why not use a topical JAK inhibitor?

Would topical metformin or PRP have achieved the same outcome?

Topical agents are attractive options in scarring alopecia given that the inflammation is so much higher up in the skin than in alopecia areata. The argument has always been that topical JAK inhibitors just can penetrate deep enough to target the peribulbar inflammation in alopecia areata. In CCCA, the inflammation is just 2 mm under the skin instead of 4-6 mm.

More studies are needed but this is interesting!

REFERENCE

Workman K and Kindred C. Hair regrowth in a patient with central centrifugal cicatricial alopecia after a 2-month trial of baricitinib. JAAD Case Rep. 2023 Jul 28:39:109-111.

Roche F et al. Activation of STAT3 in lymphocytes associated with central centrifugal cicatricial alopecia. J Am Acad Dermatol 2023 Feb 21:S0190-9622(23)00202-5.