High-Dose Baricitinib for Severe Alopecia Areata with Suboptimal Response to Conventional Therapy: A Real-World Assessment.

BACKGROUND

Severe alopecia areata (AA) causes substantial psychosocial burden, with suboptimal response rates to approved baricitinib 4 mg. Pharmacologic strategies for dose escalation, supported by inter-specialty evidence, may address this therapeutic gap.

AIM: To evaluate efficacy and safety of baricitinib 6 mg daily in severe, refractory AA patients who showed suboptimal response to conventional therapies.

METHODS

In this retrospective study, four females (mean age 26.5 years) with severe AA (mean baseline Severity of Alopecia Tool, SALT 64.5) received baricitinib 6 mg between January 2023 and June 2025. Efficacy was assessed via serial SALT score changes; safety through standardized laboratory monitoring.

RESULTS

Following escalation to baricitinib 6 mg daily, clinically meaningful SALT improvement was achieved in three patients (75%). Transient laboratory abnormalities occurred in 3 patients (75%), including asymptomatic mild platelet count elevation, self-resolving mild anemia (within normal ranges) and asymptomatic creatinine elevation. No severe adverse events occurred.

CONCLUSION

Baricitinib 6 mg daily demonstrated enhanced efficacy in 75% of patients with severe refractory AA and exhibited an acceptable short-term safety profile under close monitoring. These findings support further investigation of step-up dosing strategies in randomized controlled trials.