Topical Tofacitinib vs Topical Ruxolitinib in Frontal Fibrosing Alopecia (FFA)

Topical JAK Inhibitors for Treating FFA

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to the use of topical JAK inhibitors in treating frontal fibrosing alopecia.

Question

Hi Dr Donovan.

What's better for treating frontal fibrosing alopecia - topical ruxolitinib or topical tofacitinib?

Thank you.

Answer

We don't have a good sense yet of exactly how well the topical JAKs work in FFA. I know with confidence that they do help - we just don't know how much they help and if a certain JAK inhibitor helps more than others. The problem with many topical JAKs is that they may differ if they need to be compounded. For example, topical 2 % tofacitinib made by a compounding pharmacy up the street may differ from topical tofacitinib made by a pharmacy down the street. There are a lot of things we still don't know.

Topical ruxolitinib now has a standard product in the United States for treating vitiligo and atopic dermatitis. It’s called Opzelura and it comes as a 1.5 % cream. This is a nice option becuase it’s premade so patients are guaranteed to get the same product every time. It’s expensive and off label and not generally covered my insurance.

But it’s a good option too.

Overall, I put the topical JAKs as a solid second line option.

I'm not convinced that topical JAKs are absolutely amazing in FFA but I am convinced that they do have a role to help. So if we have a pretty good plan in place and the patient’s FFA needs more help to settle - topical JAKs are an option. Good studies precisely evaluating these agents and comparing topical ruxolitinib and topical tofacitinib are needed.

There are good studies emerging showing that the JAK pathway is probably a lot more relevant in FFA than we ever realized. We’ve reviewed these studies in the past. The link is below:

Thanks again for the question.

REFERENCE

Dubin C et al. Scalp and serum profiling of frontal fibrosing alopecia reveals scalp immune and fibrosis dysregulation with no systemic involvement. J Am Acad Dermatol. 2022 Mar;86(3):551-562. doi: 10.1016/j.jaad.2021.05.016 -