Q&A: David Cotter, MD, PhD, Advancing Alopecia Areata Care With Systemic Therapies

At the 2025 Society of Dermatology Physician Associates (SDPA) Annual Summer Dermatology Conference in Washington, DC, David Cotter, MD, PhD, delivered a lecture titled “JAK-ing Up Alopecia Areata.” Cotter, a board-certified dermatologist at Las Vegas Dermatology in Nevada, offered attendees an in-depth look at the pathophysiology, clinical spectrum, and evolving treatment landscape of alopecia areata. His talk emphasized an evidence-based approach to systemic therapies, including JAK inhibitors, conventional immunosuppressants, and dupilumab, highlighting their varying efficacies and tolerability profiles.

In this Q&A, Cotter expands on key takeaways from his session, shares practical treatment pearls, and provides guidance on selecting and initiating appropriate therapies for patients with alopecia areata.

David Cotter, MD, PhD | Las Vegas Dermatology

Q&A

Q: Alopecia is increasingly understood as an immune-mediated disease. Can you walk through the rationale for targeting the JAK/STAT pathway?

A: Alopecia areata is increasingly becoming more understood as an immune- mediated disease, and when we think about the components of the immune system that are mediating this hair loss- type condition, it's actually the T cell compartment. It's a disease where the T cells are attacking the hair follicles, and what's typically an immune-privileged space. We actually have T cells migrating into an area of the hair follicle and causing inflammation that results in hair loss. What we see clinically is usually coin or circular-shaped areas of non scarring alopecia that can transform and extend to be complete hair loss in the entire body, and things like alopecia universalis.

Because of that, it makes a lot of sense to target the T cells to treat this disease, and when we think about some of the best T cell targeting medications that we have available to us, those are JAK inhibitors. JAK inhibitors specifically inhibit the signaling pathways that are critical to T cells to not just flourish and develop but also mediate some of the pathologic effects. JAK inhibitors are so safe across the board that they're able to really dial down to the pathomechanisms of disease, providing very few off target effects for our patients.

Q: Are there specific clinical or phenotypic patterns in alopecia that respond better or respond worse to JAK inhibitors?

A: When I think about the entire panoply of phenotypes we have for alopecia areata, it runs the spectrum to focal discrete disease, 1 or 2 small areas, and usually we're not reaching for a JAK inhibitor for those patients. But that extends all the way to folks that have things like alopecia universalis, complete hair loss on the entire body, and everything in between. As we drill down and think about what disease types tend to respond the best, usually people that have more limited disease do better. It certainly is harder to treat alopecia universalis and totalis. Although there are some medications that work better in those arenas, there's other types of alopecia areata that are more difficult to treat.

The ophiasis pattern, which is typically a band-like distribution of alopecia that runs from the temporal scalp down to the occipital scalp, it is historically more difficult to treat, but with JAK inhibitors, it really does even out the playing field, and with these new medications, most people are able to get meaningful hair regrowth within a matter of time. When we think about what that matter of time is, though, it's never fast enough for anyone; we're talking about months, sometimes even out past a year, to get complete or clinically meaningful hair regrowth.

Q: With FDA-approved and other JAK inhibitors under investigation, how do you approach treatment selection in patients with alopecia?

A: When I'm seeing a patient in clinic with alopecia areata, I always consider the patient's disease severity, their comorbid diseases, and then the therapeutic landscape. For the sake of discussion, we can focus in on patients that have more widespread scalp disease, people that we'd be considering systemic therapy. When we think about systemic medications, there's a few that are FDA-approved specifically to treat alopecia areata. One is baricitinib. Another is ritlecitinib, and more recently, duruxolitinib.

In addition, there's also off-label use of JAK inhibitors like upadacitinib and abrocitinib that have been used, and even dupilumab, which is in clinical studies, in addition to upadacitinib being in clinical studies to treat alopecia areata. We've got a wide array of medications to choose, from 3 that are currently FDA-approved, on-label for the disease, and others that are in investigation. Looking at large network meta analysis to ask the question: Which drug is most effective at currently FDA-approved doses? It's probably duruxolitinib, which is a new medication that most of you probably haven't used yet because its launch was delayed for a variety of legal factors. It was tied up in litigation, but soon it will be available for our patients. Outside of duruxolitinib, ritlecitinib is probably is the most effective medication we had before then at current FDA-approved doses, we think about baricitinib. We have 2 different dose options: the 4 milligram and the 2 milligram dose. Certainly 4 milligrams works better than 2 milligrams and is just as safe. Every time I can get a patient on 4 milligrams of baricitinib, I do that over the 2 milligram dose. Reasons why we'd start at 4 milligrams would be alopecia totalis, alopecia universalis, or widespread alopecia areata that might even involve things like the eyebrows or the eyelashes.

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