Strong efficacy of ritlecitinib 50 mg and baricitinib 4 mg in alopecia areata, but further research needed to establish superiority

Abstract

We are living an exciting era in the treatment of alopecia areata (AA). The arrival of Janus kinase (JAK) inhibitors such as baricitinib and ritlecitinib is not only transforming our therapeutic approach but also, most importantly, changing patients' lives. These targeted treatments offer real hope in a disease that can have devastating psycho-emotional effects on affected patients.¹

In this context, the systematic review and indirect treatment comparison (ITC) by Aceituno et al.² is a timely and methodologically ambitious effort to compare the efficacy of ritlecitinib and baricitinib in severe AA, using advanced statistical approaches such as multilevel network meta-regression and matching-adjusted indirect comparisons.

One of the most encouraging takeaways from this study is that both baricitinib and ritlecitinib demonstrate strong efficacy signals, with meaningful rates of hair regrowth at Week 24. This is genuinely good news for patients and clinicians alike: we now have two therapies with proven benefit, expanding our arsenal and enabling more personalized care. These results reinforce the clinical value of JAK inhibitors in AA.

The authors found no significant difference between ritlecitinib 50 mg and baricitinib 4 mg on key endpoints, although there was a statistically significant difference favouring ritlecitinib over baricitinib 2 mg for achieving SALT ≤20. While the odds ratio data are promising, it is important to remember that when outcomes are common (>10%), odds ratios may overestimate the effect size, potentially leading to misinterpretation. In everyday practice, clinicians may perceive ORs as relative risks, which can distort the real-world impact.

It is also crucial to consider the underlying population differences. The authors acknowledge the heterogeneity between trials but miss a key point: the sample sizes differ significantly, with only 118 patients receiving ritlecitinib 50 mg (including ~27 adolescents), compared to nearly 900 adults across the baricitinib trials.^{3, 4} The exact number of patients analysed from the clinical trials of ritlecitinib is not disclosed in the main article, which makes it more difficult to interpret the data.

Nevertheless, the study offers a valuable insight: we have two effective systemic therapies for a disease that has long been frustrating to manage. As more real-world data and long-term outcomes emerge, clinicians will be better positioned to tailor treatment based on patient-specific factors, preferences, and comorbidities.

Still, the fundamental question—what is the most effective treatment for AA?—remains unanswered. Only direct, head-to-head clinical trials can resolve this and allow for confident therapeutic decision making. Until then, studies like this help build the bridge between clinical research and practical care.

In the meantime, we should celebrate the progress. The field is evolving rapidly, and our patients are already benefiting from these new possibilities.

This work has not received any funding.

Sergio Vañó-Galván: consulting fees from Pfizer, Cantabria Labs, Olistic Science, ISDIN, Viñas. L'Oreal, payment for lectures: Pfizer, Lilly. David Saceda-Corralo: None.

This work (integrated in our FFA field of research) has received Ethical approval.

Not applicable.