Trichoscopic Markers and Clinical Response Patterns With Ritlecitinib in Severe Alopecia Areata: 24‐Week Outcomes From a Prospective Real‐World Cohort

Background and Objectives Ritlecitinib is a selective Janus kinase 3 and TEC family kinase inhibitor approved for the treatment of severe alopecia areata (AA). Real‐world prospective data remain limited, particularly regarding response dynamics beyond mean severity scores. The objective of this study was to evaluate the real‐world effectiveness and safety of ritlecitinib in patients with severe AA and to characterize patterns of treatment response by integrating clinical severity metrics and trichoscopic findings. Methods This prospective single‐center cohort study included adults with severe AA (baseline Severity of Alopecia Tool SALT ≥ 50) treated with ritlecitinib 50 mg once daily. Clinical assessments were performed at baseline and Weeks 4, 12, and 24. Outcomes included longitudinal changes in the SALT score, achievement of SALT ≤ 20, transitions across severity categories, and trichoscopic markers of disease activity and regrowth. Safety and laboratory parameters were monitored through Week 24. Results Thirty patients completed follow‐up through Week 24. Mean SALT decreased from 79.7 ± 22.0 at baseline to 44.5 ± 37.2 at Week 24. Thirteen of 30 patients (43.3%; 95% CI: 27.4–60.8) achieved SALT ≤ 20 by Week 24. Distribution‐based analyses demonstrated a progressive shift toward lower SALT values and transitions from severe to milder disease categories in a subset of patients. Trichoscopic evaluation showed an early and progressive increase in regrowth hairs from Week 4 onward, while traditional activity markers remained frequently detectable. Patient‐reported outcomes also improved over follow‐up, with significant reductions in Skindex‐16 and HADS anxiety and depression scores. No serious adverse events or treatment discontinuations occurred; laboratory parameters remained largely stable. Conclusions In this prospective real‐world cohort, ritlecitinib demonstrated clinically meaningful effectiveness and a favorable midterm safety profile in severe AA. Integrating continuous, categorical, and trichoscopic outcomes provides a nuanced characterization of treatment response beyond mean severity measures alone.