A Real-World Case: Initiating Ritlecitinib After Years of Untreated Disease

Patients with longstanding alopecia areata who have cycled through prior clinical encounters and been told that no meaningful treatment options exist represent a distinct and emotionally complex patient population. By the time such individuals present to a dermatologist, they have often developed an adaptive relationship with their hair loss: wearing hairpieces or scalp coverings as part of a daily routine, avoiding settings in which their alopecia might be visible, and-critically-having long since stopped expecting medicine to offer anything new. The psychological armor these patients have constructed is understandable and appropriate given the advice they received, but it also means that re-engaging them in treatment planning requires care and credibility.

The clinician must not only introduce the existence of effective new therapies but must also counteract years of accumulated hopelessness in a way that feels grounded rather than oversold.

When a patient in this category is identified-whether through a scheduled consultation or, as sometimes happens, incidentally during a skin exam performed for a separate indication-treatment selection is guided by the same shared decision-making framework applied to any new systemic therapy candidate, with particular attention to the patient's comorbidities, existing medication burden, and personal preferences around dosing. Ritlecitinib, with its straightforward once-daily oral administration and well-characterized safety profile in both adult and adolescent populations, has emerged as a natural fit for patients who want to integrate a new medication as seamlessly as possible into an existing routine. Comorbidities that limit eligibility for other agents may further narrow the decision, and the prescribing dermatologist must review each option carefully before making a recommendation. For patients who have waited years for a solution, setting realistic expectations about the 6- to 12-month timeline to visible regrowth is essential-hope grounded in honesty is more durable than hope built on overpromising.

In this segment, Nader Aboul-Fettouh, MD, double board-certified dermatologist and fellowship-trained Mohs Micrographic Surgeon and founder and managing director of Blue Ribbon Dermatology in the Dallas area, describes a patient he identified during a routine skin examination who had been wearing a hairpiece for many years after being told there was nothing medicine could do for her AA. Aboul-Fettouh walks through the clinical and practical factors that guided the decision to initiate ritlecitinib-including comorbidities that precluded other agents, her strong preference for once-daily dosing. and the particular emotional significance of reintroducing genuine therapeutic hope into a case that had previously been framed, incorrectly, as untreatable.

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Aboul-Fettouh recounts a case in which an incidental skin examination revealed longstanding, undertreated AA in a patient who had been told no effective therapy existed, illustrating how the new generation of JAK inhibitors can restore both hair and hope.

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Choosing Among Approved JAK Inhibitors: Baricitinib, Ritlecitinib, and Deuruxolitinib

The approval of 3 JAK inhibitors for alopecia areata-baricitinib, ritlecitinib, and deuruxolitinib--represents a transformational moment in a field that, until very recently, had no reliable disease-modifying systemic options. For dermatologists who trained and practiced during the decades when patients with severe or progressive AA had little to offer beyond intralesional injections, topical agents, and off-label immunosuppressants with modest and unpredictable efficacy, the arrival of 3 FDA-approved oral agents is genuinely historic. Patients who 20 to 30 years ago could travel internationally seeking any treatment that reliably restored hair can now access effective therapy through a standard office visit and a prescription. Framing the current moment in those terms-as the beginning of a new treatment era rather than a routine expansion of the formulary— helps both clinicians and patients appreciate what is now possible.

Practical differentiation among the 3 agents is achievable even in the absence of head-to-head comparative trials. Ritlecitinib is approved for adolescents aged 12 and older, making it the appropriate first consideration when earlier intervention in younger patients is the clinical priority. Once-daily oral dosing, available with certain agents, may meaningfully improve adherence in patients managing complex polypharmacy regimens or those who express a strong preference for simplicity. Renal and hepatic dosing adjustments vary across the 3 drugs and must be evaluated in the context of each patient's comorbidity profile before a prescription is written. When an initial agent does not produce adequate hair regrowth after a sufficient trial period, switching to a different JAK inhibitor targeting a distinct molecular mechanism remains a reasonable and clinically supported strategy. The absence of head-to-head data does not mean the drugs are interchangeable-it means that individual patient response must guide sequencing decisions.

In this segment, Nader Aboul-Fettouh, MD, double board-certified dermatologist and fellowship-trained Mohs Micrographic Surgeon and founder and managing director of Blue Ribbon Dermatology in the Dallas area, shares how he navigates the agent-selection conversation with patients newly eligible for systemic therapy. He explains how he weighs age, comorbidities, dosing preferences, and compliance considerations in making an initial recommendation, while conveying to patients that treatment for AA is an iterative process—with multiple viable, FDA-approved options-rather than a single high-stakes decision.

Aboul-Fettouh reviews the 3 FDA-approved JAK inhibitors for alopecia areata, highlighting key differentiators-age indication, dosing convenience, renal and hepatic adjustment requirements, and the potential to switch agents when initial therapy fails to achieve adequate regrowth.

Raghuveer Vedala, MD, is a clinical physician at the Norman Regional Health System.

Shagun Bindlish, MD, FACP, FOMA, DABOM, DACLM, is an internist and diabetologist with advanced expertise in obesity and lifestyle medicine. She serves as medical and scientific chair for the ADA Northern California and is the founder of the Golden State Obesity Society. An educator at Touro University California and University at Sea CME, she has trained providers worldwide in metabolic health. 

Recognized with the Obesity Medicine Association’s Outstanding Contribution Award in 2024, she is also nominated by her peers for the Compassionate Physician of the Year Award by the California Medical Association. Her work focuses on advancing diabetes and obesity care through innovation, education, and advocacy.

Pediatrics, Retention, and Lifestyle Changes in Obesity

The Obesity Medicine Association (OMA) Annual Conference 2026, in San Diego, California, featured >80 scientific and educational sessions covering everything from nutrition, physical activity, clinical pharmacology, and practice management for 

 care. From major steps forward in incretin therapies to the release of the updated OMA Obesity Algorithm, this year’s meeting brought tons of new data to the forefront of endocrinology care.

In the fifth and final episode of a 5-part 

, Raghuveer Vedala, MD, and Shagun Bindlish, MD, discuss the most impactful headlines to come out of OMA 2026 – as well as how these findings can be applied to everyday obesity management and treatment.

The discussion shifts to evolving approaches to pediatric and adolescent obesity management alongside broader shifts in how clinicians define treatment success. The speakers note that while off-label use of tirzepatide is being seen in adolescents, longer-term pediatric trial data are still pending, with expectations that more definitive evidence may emerge in the coming years. In contrast, currently approved therapies for adolescents include Wegovy and Saxenda (for ages 12 and older). A key theme is the reframing of success in obesity care: rather than focusing solely on scale-based targets, clinicians are encouraged to recognize meaningful clinical improvements—such as better blood pressure control, reduction in diabetes risk, improved sleep apnea, and enhanced overall function—even when weight loss is modest (e.g., 5–10%).

The speakers emphasize that weight plateaus are expected and reflect physiologic “set point” dynamics rather than treatment failure. They stress the importance of individualized expectations, avoiding overly restrictive eating patterns that may lead to nutritional deficiencies or unhealthy relationships with food, and instead prioritizing sustainable dietary habits, smaller balanced meals, and careful titration of therapy to manage side effects. In older adults, the discussion shifts further toward preserving lean mass and function, highlighting the need for assessments such as DEXA scanning, grip strength, gait speed, and structured resistance exercise to prevent sarcopenia and maintain independence while treating obesity.

Finally, the conversation broadens to a systems-level perspective on obesity care. GLP-1–based therapies are framed as tools that support behavior change rather than replacements for lifestyle foundations such as nutrition quality, physical activity, and a healthy relationship with food. The speakers underscore that success should ultimately be measured by improvements in quality of life and functional capacity—“making the immobile mobile”—rather than weight alone. They also highlight the impact of stigma and access barriers, noting that bias can influence physiology and that loss of coverage can undermine patients’ belief in recovery. Resources from the Obesity Medicine Association are recommended to support clinicians in adopting evidence-based, patient-centered obesity management approaches.

In the final segment of this 5-part HCPLive Special Report, experts recap the Obesity Medicine Association Annual Conference 2026.

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OMA 2026 Recap: Pediatrics, Retention, and Lifestyle Changes in Obesity

GLP-1s in Conditions Beyond Obesity

The discussion centers on the expanding role of GLP-1 receptor agonists, particularly semaglutide, in obesity and related metabolic disease, and how recent clinical data are reshaping practice. A major focus is the ESSENCE trial in metabolic dysfunction–associated steatohepatitis (MASH), where semaglutide 2.4 mg demonstrated significant histologic benefit, with steatohepatitis resolution in roughly 63% of treated patients versus 34% with placebo. This has contributed to increased clinical confidence following accelerated regulatory action and updated guidance supporting GLP-1–based therapy in patients with obesity and MASH. The speakers emphasize that this is also helping unify care across specialties—endocrinology, hepatology, gastroenterology, and primary care—under a broader metabolic syndrome framework rather than siloed disease management.

Beyond weight loss, the conversation highlights emerging mechanistic insights suggesting GLP-1 therapies may exert direct cardiometabolic and anti-inflammatory effects. These include potential modulation of inflammatory pathways such as interleukin-6 signaling, which may help explain observed cardiovascular and renal benefits beyond what would be expected from weight reduction alone. At the same time, new safety considerations are discussed, including post-marketing signals related to psychiatric adverse events such as suicidality, which remain unconfirmed causally but are prompting closer monitoring and proactive patient counseling. Additional emerging adverse effects, such as dysesthesia and neuropathic-type sensations reported with higher-dose formulations, are also noted, reinforcing the importance of individualized risk–benefit assessment and surveillance.

The discussion then shifts to bariatric surgery as an enduring pillar of obesity treatment alongside pharmacotherapy. Updated BMI thresholds are reviewed (≥35 kg/m² regardless of comorbidity, or 30–34.9 kg/m² with metabolic disease), and the speakers emphasize that surgery remains highly effective, particularly for patients who do not tolerate or respond adequately to GLP-1 therapies. Practical perioperative considerations are highlighted, including evolving guidance on holding GLP-1 agents prior to surgery due to delayed gastric emptying and aspiration risk, as well as the potential role of preoperative liquid diets and point-of-care ultrasound assessment. Overall, the segment reinforces a patient-centered, multimodal approach in which medications, surgery, and lifestyle interventions are integrated rather than viewed as competing strategies.

In the fourth segment of this 5-part HCPLive Special Report, experts recap the Obesity Medicine Association Annual Conference 2026.

OMA 2026 Recap: GLP-1s in Conditions Beyond Obesity

The Side Effects of GLP-1s for Obesity

Vedala shifts the discussion from emerging oral formulations of GLP-1 therapies to a key concern in obesity medicine: the impact of weight loss medications on lean mass, particularly muscle. The speakers highlight that while GLP-1–based therapies can produce substantial weight loss, a meaningful portion may come from lean mass, raising concerns about sarcopenia, frailty, bone health, and long-term functional outcomes, especially among older adults and women. Bindlish and Vedala discuss findings from studies such as SEMALEAN, which suggested that a significant percentage of weight loss with semaglutide may involve lean mass, while emphasizing that adequate protein intake and resistance training are essential strategies to help preserve muscle. Early data from the BELIEVE trial evaluating bimagrumab combined with semaglutide was also discussed as a potential future approach to improving fat loss while maintaining lean mass, though the evidence remains preliminary.

The conversation emphasizes that obesity treatment should not rely solely on medication, particularly as more GLP-1 therapies and other agents enter the market. The clinicians expressed concern that many patients are obtaining weight-loss medications through online platforms or compounded sources without receiving appropriate counseling on nutrition, exercise, muscle preservation, or baseline assessments such as body composition measurements. They stressed that medications should be viewed as tools that complement, rather than replace, lifestyle interventions. Resistance exercise, protein optimization, and comprehensive obesity medicine evaluations should become standard components of care to support long-term health, function, and longevity.

In the third segment of this 5-part HCPLive Special Report, experts recap the Obesity Medicine Association Annual Conference 2026.

OMA 2026 Recap: The Side Effects of GLP-1s for Obesity

In the second segment of this 5-part HCPLive Special Report, experts recap the Obesity Medicine Association Annual Conference 2026.

OMA 2026 Recap: Oral Pharmacotherapy for Obesity

In the first segment of this 5-part HCPLive Special Report, experts recap the Obesity Medicine Association Annual Conference 2026.

OMA 2026 Recap: Defeating the Stigma of Obesity

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Latest News

A Real-World Case: Initiating Ritlecitinib After Years of Untreated Disease

Choosing Among Approved JAK Inhibitors: Baricitinib, Ritlecitinib, and Deuruxolitinib

OMA 2026 Recap: Pediatrics, Retention, and Lifestyle Changes in Obesity

OMA 2026 Recap: GLP-1s in Conditions Beyond Obesity

OMA 2026 Recap: The Side Effects of GLP-1s for Obesity