JAK Inhibitors, Oral Minoxidil Reshape Hair Loss Care

Benjamin Ungar, MD, director of the Alopecia Center of Excellence at the Kimberly and Eric J. Waldman department of dermatology at Mount Sinai, said the emergence of Janus kinase (JAK) inhibitors has been the single biggest advance in hair loss treatment over the past 2 years, reshaping care for both alopecia areata (AA) and scarring alopecia.1 Ungar discussed the shift during his session, “Hair Update 2026,” at the Maui Derm NP+PA Summer 2026 conference in Colorodo Springs.

Currently, 3 oral JAK inhibitors are approved in the US for severe AA: baricitinib (Olumiant), ritlecitinib (Litfulo), and deuruxolitinib (Leqselvi).2 Ungar noted that newer anti-inflammatory approaches, including topical and off-label oral JAK inhibitors, are also beginning to move the needle on scarring alopecia, a historically difficult subtype to treat.

Long-Term Cardiovascular Safety

Ungar has published research characterizing the long-term safety of JAK inhibitors in AA, an important consideration given that treatment is typically ongoing rather than time limited. His findings, along with data from other groups, suggest that JAK inhibitor use in AA does not meaningfully increase the risk of major adverse cardiovascular events (MACE) or thromboembolic events beyond background population rates, even over several years of follow-up.3

All 3 approved agents carry a US Food & Drug Administration (FDA) boxed warning for class-wide risks, including serious infection, malignancy, MACE, and thrombosis, based largely on post-marketing data from rheumatoid arthritis populations treated with a different JAK inhibitor.3 Ungar's data adds to a growing body of AA-specific evidence that has not shown new or unexpected safety signals to date.

Low-Dose Oral Minoxidil in Practice

Low-dose oral minoxidil (LDOM) has become an increasingly common option across hair loss subtypes, according to Ungar. He uses it as monotherapy in some patients and in combination with other treatments in others, applying it broadly to androgenetic alopecia and telogen effluvium alike.

Dosing typically starts at 1.25 mg for women and 2.5 mg for men, with titration upward as tolerated, Ungar said. Cardiovascular effects such as hypotension and tachycardia, along with rare pericardial effusion, remain the primary safety concerns, though Ungar noted that large-scale clinical experience has shown these events to be uncommon and that LDOM is generally well-tolerated.

The most frequent adverse effect is hypertrichosis, which Ungar counsels patients to expect before starting treatment. In his experience, most patients who develop unwanted hair growth still choose to continue therapy because of the benefit to scalp hair.

Where Nutraceuticals Fit in Hair Loss

Direct-to-consumer marketing of hair growth nutraceuticals continues to expand, but Ungar said evidence should guide how clinicians position these products. Some formulations have data supporting benefit, particularly in patients with underlying nutrient deficiencies or insufficiencies that can affect the hair cycle. Ungar generally views nutraceuticals as adjunctive rather than core therapy, noting that aside from cost, there is typically little downside to their use alongside evidence-based treatment.

Sequencing Therapy for Alopecia Areata

Ungar said severity remains the primary driver of treatment selection in AA. Mild disease is generally managed with intralesional steroid injections, while severe disease warrants systemic therapy. Moderate disease occupies a gray zone in which injections alone may be insufficient.

“Once someone is determined to be a candidate for systemic treatment, in most cases, oral JAK inhibitors are the first-line treatment,” Ungar said. “I think that we as a field should be shifting away from more traditional immunosuppressants like systemic steroids… and really should be using oral JAK inhibitors to treat patients who are systemic candidates because of the higher degree of efficacy and overall better safety profile.”

References

1. Ungar B. Hair Update 2026. Presented at Maui Derm NP+PA Summer 2026 in Colorado Springs.

2. FDA-approved JAK inhibitors. National Alopecia Areata Foundation. Accessed July 8, 2026. https://www.naaf.org/navigation-toolkit/fda-approved-jak-inhibitors/

3. Green L, Guttman E, Lebwohl M, et al. Exploring novel management options for alopecia areata. AJMC. Published on March 3, 2026. Accessed July 8, 2026. https://www.ajmc.com/view/exploring-novel-management-options-for-alopecia-areata