Managing Pediatric Alopecia Areata: Part 2
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In this second part of our 2-part interview with Dr Brittany Craiglow, she discusses treatment options for children with alopecia areata (AA), including off-label therapies, while acknowledging the complexities of obtaining medication approval and addressing long-term risks.
The Dermatologist: What treatment options are available for children with AA and how do you tailor these treatments?
Dr Craiglow: Treatment can be very challenging, especially in kids. Ritlecitinib, a Janus kinase (JAK) inhibitor, is the only US Food and Drug Administration-approved treatment for patients aged 12 years and up for severe AA. It is great to have something on label for our teenage patients. Middle school and high school are tough even when you have your hair; add AA to the mix and it can be really difficult. I think JAK inhibitors are the most reliably effective treatment that we have. They are targeted, pathogenesis-based, and tend to be very well tolerated. I do use JAK inhibitors off label in younger children. There are multiple JAK inhibitors that have approvals for other indications in children as young as age 2, so we have some systematic data in pediatric populations about weight-based dosing. In the United States, there are 2 JAK inhibitors approved for juvenile arthritis, and one thing I often find myself saying in the clinic is if this were arthritis, we would not hesitate, we would just treat. There are for sure unknowns, but I think in a lot of ways AA can be as debilitating as arthritis, just in a different way. Obviously, it depends on the patient, the family, and the circumstances, but I think we are often looking for something to restore normalcy to their life. Because this is something that can have such a profound impact on a child and their trajectory, I think often we just need to do the thing that is going to make it better.
This is the art of medicine; there is not a one-size-fits-all approach. There are so many things we think about before starting therapy. How old is the patient? How much hair loss do they have? How much is it affecting them? Have they tried anything? How motivated are they? How averse to risk or not? Fortunately, most patients have mild disease. For a patient who comes in with a patch or 2 or 3, we can often use local therapy. In older kids and adults, we often use intralesional triamcinolone, which is still the mainstay of therapy for limited disease. But one of my rules with treating children is that you never want the treatment to be worse than the disease, so I do not think injections are appropriate for younger children. I usually do not even bring it up until a child is maybe 10 or 12. And even then, I say, “You do not have to do this.” Some kids are really motivated, and they can tolerate it, but if it causes distress, I think it is not worth it.
Sometimes we will use topical corticosteroids. Although they have fairly limited efficacy, they can be useful. My approach is usually throwing the book at it. Any intervention we make, we have to wait 2, 3, 4 plus months before we have an idea if it is going to work. It is better to do multiple things at the start and then pull back eventually rather than trying one thing and in 4 months you have gotten nowhere. I go more full force from the beginning and then see where the patient gets for more moderate hair loss. For patients with chronic patchy disease, I use a lot of low-dose oral minoxidil. Most people are primarily using it for pattern hair loss (androgenetic alopecia), but there really is a role in AA. There was a paper many years ago in the 1980s demonstrating the efficacy of oral minoxidil monotherapy for AA. For some patients, I think it is a useful adjunct to treatment, but also even by itself it can sometimes be helpful. For patients who have chronic waxing and waning disease, they are always worried that it is going to get worse.I think in some of those cases, minoxidil prevents the waxing and waning. We have also shown that it can be useful in combination with JAK inhibitors.
There are provocative data about using dupilumab, which is a medicine we have become very familiar with in dermatology. I would say if you take all comers, it does not work well for AA, but in children who have an atopic background who have elevated immunoglobulin, sometimes it can actually be quite useful. Dupilumab is approved down to age 6 months, so if your pediatric patient with AA has atopic dermatitis, or asthma, or allergies, or something to warrant it anyway, it is a nice option because of the approval and its great safety profile. I have many patients who have done very well on dupilumab plus oral minoxidil, for example. Sometimes we just have to be creative and put things together.
For pediatric patients with AA, we are weighing the risk of the treatment vs the risk or the consequence of not treating. What does it mean to finish elementary school and then go to middle school without hair or maybe not even going to school because kids are making fun of you and you are embarrassed, so suddenly you are being homeschooled? We have kids who are excellent athletes and then they stop playing because they are not able to wear a hat on the field. The risk of not treating is high for most patients. And that is a big part of the discussion. There are clinical trials in younger patients coming, so I do think that in time we will have approved options for younger children. But these trials take a long time because hair takes a long time to grow. In the meantime, sometimes we do need to work outside the box. The other important thing for people to know is that after a period of time, probably 3 to 4 years of no hair, a person’s chance of responding to even a targeted treatment like a JAK inhibitor starts to decrease. Patients who have severe hair loss for many years have a decreased chance of responding, and so sadly there are children out there who are going to lose their opportunity at ever having hair if somebody does not treat them soon. This is another part of our discussion with families.
I think a lot of dermatologists have this idea that treating hair loss is hard and it takes a long time and people cry. And while that is true, we have more treatment options now and it is really different from even just a few years ago when there was nothing. It is so rewarding to see these kids come back and their life is so different because of a decision that you made with them or with their family. Having that longitudinal relationship over time keeps me going. And I think if more dermatologists had a taste of that, they would want to do more because it really is impactful. One thing is for sure: When your patient grows hair, it is really rewarding and meaningful.
The Dermatologist: In your experience, what are some of the challenges or unique considerations when managing AA in pediatric patients, and how do you navigate these challenges in your practice?
Dr Craiglow: For me, probably the biggest challenge is access to medications, especially trying to get medications approved off-label. For example, JAK inhibitors, which have a high price tag, can be a difficult endeavor. My office staff spends a lot of time on the phone with insurance companies and I write a lot of letters. Often, with enough persistence on the part of the physician, the office, and sometimes even the family, we are able to get these medications approved. As much as we grumble about insurance, we are lucky in the United States in that we can sometimes get off-label medications. I have a lot of colleagues outside the United States for whom if something is off label, it is impossible. I think the trickiest thing is sorting out what angle do we take, which of the medicines makes the most sense, and how can we convince the payer this is something that really warrants therapy? If you are an adult and you have severe AA, there are now 2 choices, and so that becomes a lot easier. And I think with time it will become easier for pediatric patients also. Clinical trials are going to be a great option for younger patients.
When your patient is a child, you also have their parent or parents. I think for parents, it is a lot easier to make a decision about their own health compared to their child’s health. Every parent wants their kid to get better or their life to be back to normal, but there is always this concern of causing harm in the long run. And with JAK inhibitors, there are some unknowns about super long-term risk. We have lots of data to inform our conversations about risk, but it can be tricky and there really is not a right answer. It is more just what feels right to the family. However, because this disease is so life-altering, most families are willing to tolerate a little bit of risk for the chance at normalcy, but this is another part of the puzzle that we must think about when we are treating children.
The Dermatologist: Are there any tips or insights you would like to share with your dermatology colleagues regarding AA in children?
Dr Craiglow: One thing I want to move forward is that AA is becoming a treatable disease. A lot of patients continue to be told there is nothing we can do for you, and that is just simply not true. There are options. It is tricky with very young children, but one thing I think is helpful is to say, “Maybe this is not something we are going to do today, but there are going to be options in the future.” Instead of shutting things down right from the get-go, we can give hope to people with this disease in a way that there was not before. Now that we have an approved medication for teenagers, I think if dermatologists can treat adults, they can feel empowered to treat teenagers, especially when there is an on-label option. If you are not comfortable using these medications for younger kids, help parents find somebody who is.
Try to treat the child as if they were your own and try to envision what it would be like to have a child who has no eyebrows, or eyelashes, or scalp hair and what that means trying to navigate the world. I think the biggest thing is to just acknowledge the difficulty of the experience. Check in with your patient and their family, acknowledge that it is hard, and ask how they are doing. And connect them with the National Alopecia Areata Foundation so they know they are not alone and they have a place to go for more information.
