Disease severity, phenotype predict systemic treatment response in pediatric alopecia areata

Baseline disease severity and clinical phenotype were the strongest predictors of response to systemic treatment among children with alopecia areata (AA), according to findings from a retrospective cohort study published in the Journal of the American Academy of Dermatology.

The findings may help clinicians identify which patients are more likely to respond to methotrexate, Janus kinase (JAK) inhibitors, or oral minoxidil. The investigators noted that pediatric AA is a chronic autoimmune disorder associated with psychosocial burden and that responses to available therapies remain variable.

“Baseline disease severity and clinical phenotype emerged as the strongest predictors of systemic treatment response in pediatric AA,” the investigators wrote.

How was treatment response evaluated?

Investigators conducted a single-center, retrospective cohort study of pediatric patients with AA who received systemic therapy between January 2019 and August 2026. Systemic therapies included methotrexate, oral minoxidil, and JAK inhibitors, while adjunctive therapies included oral or topical minoxidil and topical corticosteroids. Primary outcomes were treatment response and change in Severity of Alopecia Tool (SALT) score.

The analysis included 93 patients and 626 unique visit observations. Mean age at AA onset was 6.7 years, and mean episode duration was 21.9 months. Patchy AA was the most common phenotype, occurring in 54% of patients, followed by alopecia totalis in 33%. Eyebrow, eyelash, and body hair involvement were reported in 46%, 36%, and 32%, respectively.

Methotrexate accounted for 411 treatment observations, compared with 125 for JAK inhibitors and 78 for oral minoxidil monotherapy. Overall, 88% of patients demonstrated a treatment response during at least 1 observation.

Higher baseline SALT scores linked to lower response

Across all 3 treatment groups, greater baseline disease severity was associated with reduced odds of treatment response. For every 10-unit increase in SALT score, the odds ratios (ORs) for response were 0.83 with methotrexate (P < .0001), 0.79 with JAK inhibitors (P = .0003), and 0.82 with oral minoxidil (P = .005).

Among patients treated with methotrexate, female sex (OR, 2.48; P = .0039), sisaipho pattern (OR, 3.19; P = .0277), and elevated C-reactive protein (OR, 1.95; P = .0263) were associated with increased odds of response. Complete scalp alopecia (OR, 0.49; P = .0405) and eyelash involvement (OR, 0.49; P = .0292) were associated with lower odds of response.

Elevated immunoglobulin E was associated with lower odds of response among JAK inhibitor-treated observations (OR, 0.19; P = .0399). Among those receiving oral minoxidil monotherapy, eyebrow involvement predicted lower response (OR, 0.32; P = .0204).

JAK inhibitors demonstrate high response rate

Response at any point during follow-up was observed in 94% of patients treated with JAK inhibitors, compared with 84% receiving methotrexate and 77% receiving oral minoxidil monotherapy. Significant regrowth was recorded in 40% of JAK inhibitor observations, compared with 20% for methotrexate and 17% for oral minoxidil.

The investigators concluded that methotrexate appeared most beneficial for patients with moderate disease, whereas JAK inhibitors produced “rapid and meaningful regrowth across a broad range of severity.” Oral minoxidil demonstrated limited efficacy as monotherapy for severe disease and may be more appropriate as an adjunctive treatment.

Overall, the findings suggest that considering baseline SALT score, extent and pattern of hair loss, and eyebrow or eyelash involvement may help pediatric clinicians and dermatologists individualize systemic treatment decisions for children with AA.

Reference

Mehta S, Mistry J, Moshkovich M, Sugumar C, Buros Stein A, Sibbald C. Predictors of systemic treatment response in pediatric alopecia areata: a retrospective cohort study. J Am Acad Dermatol. Published online 2026. doi:10.1016/j.jaad.2026.08.008.