When JAK inhibitors are off the table: durable remission of severe alopecia areata with dexamethasone oral mini-pulse and a focused review.

BACKGROUND

Janus kinase (JAK) inhibitors have revolutionized alopecia areata (AA) treatment, but many patients remain ineligible or lack access. Corticosteroid pulse regimens provide valuable systemic alternatives in these scenarios.

CASE PRESENTATION: A 52-year-old woman with systemic lupus erythematosus and renal transplant presented with extensive AA (SALT score 90). Due to intensive immunosuppression, JAK inhibitors were deemed clinically unsuitable. She received dexamethasone oral mini-pulse (OMP) therapy: 5 mg on two consecutive days weekly for four months. At six-month follow-up, her SALT score improved dramatically to 21, achieving SALT75 response and approaching the clinically significant SALT ≤ 20 threshold. This regrowth sustained at 12 months without maintenance therapy or steroid-related adverse events.

EVIDENCE SYNTHESIS: Review of 14 clinical studies revealed OMP's high efficacy, with 89% patient improvement and 71% median SALT reduction by week 24. Randomized trials show oral steroid pulse therapy can outperform placebo (weekly prednisolone), and betamethasone OMP outperformed methotrexate in an active-comparator trial. However, relapse occurs in approximately 60% of responders post-withdrawal. Intravenous methylprednisolone pulses showed 73% response rates at 12 months, particularly in early multifocal disease.

CONCLUSIONS

In JAKi-ineligible settings, OMP provides outpatient induction with acceptable safety. This case demonstrates achievable 12-month durable remission even in complex, high-risk, immunosuppressed patients.