Introduction
Alopecia areata (AA) is an autoimmune disorder characterized by nonscarring hair loss that can affect any hair-bearing site [
1], often leading to emotional and psychosocial distress [
2‐
4]. Severe AA is unlikely to remit without treatment [
5]. Recently, baricitinib, an oral selective JAK inhibitor that has been previously approved for the treatment of rheumatoid arthritis, became the first approved systemic therapy in the USA, Europe, and Japan for the treatment of adults with severe AA [
6]. In the BRAVE-AA1 and BRAVE-AA2 phase 3 trials [
7,
8], each met their primary endpoint of a greater percentage of participants achieving Severity of Alopecia Tool (SALT) score ≤ 20 (at least 80% scalp coverage) by week 36 in the baricitinib treatment groups versus placebo, and scalp hair regrowth continued to improve through week 52 [
7,
8]. Safety data for baricitinib are well characterized across several indications [
9,
10] and safety data are available up to 2 years in AA [
8,
11,
12].
Reflecting the heterogeneity of the disease, the amount of scalp hair regrowth can vary with treatment, and other hair-bearing sites may also respond differentially to therapy. In a large case series of patients treated with tofacitinib, Liu et al. observed that patients could achieve full eyebrow (EB) and eyelash (EL) regrowth despite not achieving complete scalp hair regrowth [
13]. We have previously reported that the amount of scalp hair regrowth at week 36 was associated with improvements in emotional symptoms and quality of life [
14]. Here, we extend this analysis by examining regrowth at week 52 and whether the patients who do not achieve a SALT score ≤ 20 may experience holistically other clinically meaningful benefits, including EB/EL regrowth, improvement in psychological distress, or improvement in quality of life (QoL).
Methods
Trial Design
BRAVE-AA1 and BRAVE-AA2 were randomized, double-blind, parallel-group, placebo-controlled trials conducted at 169 centers in ten countries [
7]. The trials had identical eligibility criteria and primary and key secondary objectives for the 36-week placebo-controlled treatment periods. In BRAVE-AA1 and BRAVE-AA2, first patients entered treatment in March 2019 and July 2019, respectively, and last patients entered treatment in June 2020 and May 2020, respectively. A full description of the trial design has been previously published [
7].
Patients were initially randomized to receive placebo, baricitinib 2 mg, or baricitinib 4 mg in a 2:2:3 ratio. At week 36, nonresponder patients on placebo were rerandomized to either baricitinib 2 mg or 4 mg; however, since they had not yet had 52 weeks of active therapy, they are not included in this post hoc analysis. Patients who were treated continually with either dose of baricitinib through week 52 comprised this analysis.
Patient Eligibility
Patients were aged ≥ 18 years and ≤ 60 years for males and ≤ 70 years for females [
15]. Inclusion criteria required SALT score ≥ 50 (at least 50% of scalp hair loss) [
16] and a current episode lasting > 6 months to < 8 years, without spontaneous improvement (≤ 10-point SALT score reduction) over the past 6 months. There were no inclusion requirements for EB or EL hair loss. A full description of inclusion and exclusion criteria has been previously published [
7]. Treatment with finasteride (or other 5α-reductase inhibitors) and with oral or topical minoxidil was permitted if patients had been on a stable dose for 12 months before randomization and were anticipated to continue a stable dose until week 36. Treatment of eyelids with bimatoprost ophthalmic solution was permitted if patients had been on a stable dose for ≥ 8 weeks before randomization. However, less than 5% of patients were receiving these concomitant medications.
Clinical Outcomes
Scalp hair loss was assessed using the SALT measure [
17]. SALT scores are derived from a physician examination of the four quadrants of the scalp and are calculated so that scores are equivalent to the percentage of scalp hair loss. A SALT score ≤ 20 means there is less than 20% scalp hair loss. Scores that reflect a change from the patient’s baseline are referenced using subscript; for instance, SALT
30 means a 30% improvement from the patient’s baseline SALT score. EB and EL were assessed using the Clinician-Reported Outcome (ClinRO) for Eyebrow and Eyelash hair [
18]. A ClinRO score of 0 indicates no EB/EL hair loss, a score of 1 indicates minimal gaps, a score of 2 indicates significant loss or gaps, and a score of 3 indicates total hair loss.
Emotional distress was assessed using the Hospital Anxiety and Depression scale (HADS) [
19], and QoL impact was measured using the Skindex-16 adapted for AA (Skindex-AA) [
20]. The HADS is scored into two separate scales: HADS Anxiety and HADS Depression. Each scale can range from 0 to 21 and scores of 8–10 are interpreted as borderline abnormal, while scores ≥ 11 are considered clinically relevant [
19]. The Skindex-AA consists of 16 items grouped under three domains: symptoms (four items), emotions (seven items), and functioning (five items), and these domain scores assess how hair loss affects symptoms, emotions, and functioning. The Skindex-AA total score can range from 0 to 100, with higher scores indicating greater impairment. The Skindex-AA was administered to the majority of patients in BRAVE AA1 and to all patients in AA2 on the basis of its contract availability at the time of study initiation.
Statistical Analyses
Baricitinib patient subgroups were categorized into one of three response subgroups on the basis of their SALT score at week 52:
1.
SALT criterion response, defined as those achieving SALT score ≤ 20 by week 52.
2.
Intermediate response, defined as failure to reach SALT score ≤ 20 but achieving a SALT30 at one or more post-baseline visits by week 52; or
3.
Nonresponders, defined as never achieving SALT30 by week 52.
ClinRO Eyebrow and ClinRO Eyelash were assessed in participants who had substantial hair loss in either EB or EL (a ClinRO score ≥ 2 at baseline). Response was defined as a ClinRO score of 0 or 1 with ≥ 2-point improvement from baseline. Response rates were reported using descriptive statistics. Mean change from baseline in HADS Anxiety and Depression scores, and Skindex domain scores, were summarized by subgroups for each treatment arm. Nonresponder imputation and modified last observation carried forward were used to impute data censored after permanent drug discontinuation or data collected remotely due to the coronavirus disease 2019 (COVID-19) pandemic, for binary and continuous endpoints, respectively. Comparisons between the SALT response subgroups were conducted using analysis of variance (ANOVA) for the endpoints of the HADS and Skindex. Main subgroup effect was further tested by pair-wise t-tests for between group differences and p-values were corrected using Bonferroni method.
Ethics Approval and Patient Consent
The trials were conducted in accordance with ethical principles of the Declaration of Helsinki and Good Clinical Practice guidelines, and the research protocols were approved by each center’s institutional review board or ethics committee. All patients provided written informed consent.
Patient and Public Involvement Statement
Patients were not involved in the development of the protocol.
Discussion
The results of the present analyses suggest that the response to baricitinib therapy resulted in a continuum of scalp hair regrowth in a clinical trial population with a majority who at baseline had a scalp hair loss greater than 90%. At week 52, for patients treated with baricitinib 4 mg, approximately 40% had achieved a SALT score ≤ 20, while approximately 30% had intermediate response, and approximately 30% had a minimal response to treatment. The 40% of patients who met this response at week 52 experienced the highest rate of regrowth in EB and EL, but the findings of these analyses also suggest that patients can achieve meaningful regrowth in other hair-bearing sites even in the absence of complete or nearly complete scalp hair regrowth. Almost half of patients who had intermediate regrowth achieved complete regrowth of EB and EL, and approximately 20% of nonresponders also achieved these outcomes when treated with baricitinib 4 mg. The importance of achieving these clinical endpoints should not be understated. Wyrwich et al. found that while scalp hair loss was most identified as the most bothersome symptom of AA, EB and EL hair loss were consistently identified as being in the top three most bothersome symptoms of AA [
18]. In an online survey of 1741 adults with AA, approximately one-third would be satisfied with a treatment outcome of complete scalp regrowth but no EB regrowth; conversely, potential satisfaction with treatment increased to more than 90% if complete regrowth was achieved for both scalp and EB [
21]. The finding that EB and EL regrowth can respond in the absence of complete scalp hair regrowth further suggests biological differences among the hair-bearing sites in response to therapy.
Baseline HADS Anxiety scores of the pooled population were consistent with mild elevation in severity relative to the general population norm. In a meta-analysis of studies examining the psychological symptoms and psychiatric comorbidities of AA, patients with AA were found to be approximately 2.5 times more likely to have elevated anxiety and/or depression relative to general population [
22]. The findings presented here demonstrate that although patients who achieved the criterion response experienced the largest mean improvement in anxiety, patients with intermediate response also had higher improvements, although they did not differ significantly from the nonresponse group. In a recent mediator analysis using data from the baricitinib clinical trials, improvement in scalp hair regrowth was a direct mediator for the improvements in emotional distress; however, the mediator analyses were unable to include the potential influence of EB and EL regrowth [
23]. Given the importance of EB and EL, it may be that regrowth in these areas in the absence of complete scalp hair regrowth could also be emotionally impactful, but this conclusion cannot be determined from the present analyses.
With respect to impact on QoL, at baseline, in the pooled population, patients reported greater impact on the emotional and functioning aspects of QoL rather than on the physical symptoms. The low scores on the physical symptoms domain likely reflect the lack of disease-related symptoms such as itching, burning, or stinging. As observed in the Piracinni et al. study, the association between scalp hair regrowth and improvement in emotional distress and functioning was strongest for patients who achieved a SALT score ≤ 20 [
14]. For both the emotional and functional domains of the Skindex-AA, the magnitude of improvement was proportionally greater in those patients who were responders. These findings suggest that the functional impact of treatment necessitates that patients achieve the criterion response of at least 80% scalp coverage and reinforces the clinical relevance of a SALT score ≤ 20 as a therapeutic goal. Consistent with this interpretation, a SALT score ≤ 20 was determined by both clinical experts and patients as the threshold for therapeutic success as an amount of scalp coverage that does not require extraordinary hairstyling or camouflage efforts [
16].
In summary, the findings from the current post hoc analysis suggest that baricitinib therapy can affect hair regrowth in other hair-bearing sites in the presence of intermediate or nonresponse with scalp hair. Patients who experience scalp hair regrowth that is at least 80% scalp coverage demonstrated larger improvements in emotional status and QoL relative to other groups. Improvement in emotional symptoms and functioning was greatest among patients who achieved the criterion response for the scalp, suggesting that achieving the threshold of complete or nearly complete scalp coverage is necessary for these benefits.
Limitations of this post hoc analysis are that these comparisons resulted in subgroups that were not randomized, so differences in groups may be related to other factors than hair regrowth, such as severity or duration of current disease episode. A patient satisfaction questionnaire was not included, thus it is not possible to assess the importance of EB/EL regrowth in overall treatment satisfaction. Further, it is not possible to separate out the effects of EB/EL severity from overall scalp hair loss severity, as patients with greater scalp hair loss were also more likely to have greater EB/EL hair loss. In addition, these analyses represent the status of the patients at week 52; patients with intermediate response may experience further improvements in hair regrowth with longer treatment duration to achieve a SALT ≤ 20.
Conclusions
After 1 year of treatment with baricitinib, regrowth of EB and/or EL hair was observed in patients who did not achieve complete or near complete scalp hair regrowth. These findings suggest that clinical response to treatment may vary among hair bearing sites affected by AA, and some patients may achieve clinically meaningful regrowth of EB and EL independent of scalp hair regrowth. Emotional and functional improvement is associated with achievement of nearly complete hair regrowth. Altogether, the present findings may further help to set appropriate expectations of treatment benefits for both physicians and patients.
Declarations
Conflict of Interests
Susan Ball, Yuxin Ding, Yun-Fei Chen, and Yves Dutronc are all employees and shareholders of Eli Lilly and Company. Brett King has received fees from Abbvie, AltruBio Inc, Almirall, AnaptysBio, Arena Pharmaceuticals, Bioniz Therapeutics, Bristol-Meyers Squibb, Concert Pharmaceuticals Inc, Equillium, Horizon Therapeutics, Eli Lilly and Company, Incyte Corp, Janssen Pharmaceuticals, LEO Pharma, Otsuka/Visterra Inc, Pfizer Inc, Regeneron, Sanofi Genzyme, Sun Pharmaceutical, TWI Biotechnology Inc, and Viela Bio; he has served on speaker bureaus for Abbvie, Incyte, Eli Lilly, Pfizer, Regeneron and Sanofi Genzyme; he has presented data at a scientific venue on behalf of Eli Lilly and Company. Ohsang Kwon has received grants for research from Eli Lilly and Company, Pfizer, AddPharma, and CKD Pharm. Rodney Sinclair has received consultancy fees from Eli Lilly and Company, Pfizer, Reistone Pharmaceuticals, Abbvie and Samson Clinical and has presented data at a scientific venue on behalf of Eli Lilly and Company, Pfizer and Abbvie. Bianca Maria Piraccini has received consultancy fees from Eli Lilly and Company, Pfizer, ISDIN, Almirall, and Vichy, has received payment for presentations or speaker bureaus from Eli Lilly and Company and Pfizer, and has participated on advisory boards for Eli Lilly and Company and Pfizer. Maryanne Senna has received consultancy fees from Arena Pharmaceuticals, Eli Lilly and Company, and Pfizer, has been a speaker for Pfizer and Eli Lilly.
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