Stepwise topical corticosteroid and dexamethasone rescue strategy enhances baricitinib outcomes in severe alopecia areata: real-life clinical experience

Recent evidence suggests that the Janus kinase (JAK) inhibitor, baricitinib, when combined with corticosteroids, may have potential positive synergistic effects in patients with alopecia areata. To report our real-world experience with a systematic stepwise approach combining topical corticosteroids with baricitinib, followed by pulse dexamethasone rescue therapy in non-responders with alopecia areata. This retrospective chart review analysed medical records of 19 patients with severe alopecia areata receiving baricitinib between November 2023 and February 2025. Topical corticosteroids were used as adjunct therapy concurrent with baricitinib initiation to minimize non-responders, while patients with insufficient response at 24 weeks received pulsed dexamethasone (0.5 mg/kg, twice weekly) as rescue therapy. This approach achieved significantly higher response rates than pivotal trials, with 89.5% of patients attaining SALT ≤20 at 52 weeks. Notably, this management strategy effectively addressed Italian regulatory constraints recommending baricitinib discontinuation if significant response is not achieved within nine months. Our findings demonstrate the potential of combined targeted therapies to enhance outcomes in severe alopecia areata, overcoming treatment timeframe limitations while providing insights for individualized approaches.