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New developing multiple sclerosis in a patient using tofacitinib due to alopesia areata

Janus kinase inhibitors are treatments under investigation for many immune-mediated dermatological diseases, including psoriasis, psoriatic arthritis, atopic dermatitis, vitiligo, alopecia areata, and cutaneous lupus. Although these drugs are known to have a safety profile similar to that of other biologics commonly used in dermatological practice, side effects such as infection, malignancy, and thromboembolism have been reported. Here, an alopecia areata patient who was diagnosed with multiple sclerosis (MS) after using tofacitinib will be presented. A 46-year-old female patient was admitted to our clinic with multiple alopecic patches on the scalp that had been present for about 5 years. The patient, who was diagnosed with alopecia areata based on clinical and dermoscopic features, received topical and intralesional steroids, systemic steroids for 6 months, cyclosporine for 3 months, phototherapy for 1-year, alternative medicine applications, and PRP treatments. We started 2 5 mg/day tofacitinib treatment for the patient due to resistant disease. After 6 months of use, the SALT score increased from S3 to S1 (Figures 1 and 2). However, in the seventh month of the treatment, the patient, who developed numbness in the right half of the face and tongue, stopped tofacitinib treatment voluntarily and applied to the neurology clinic of our hospital. Brain magnetic resonance imaging (MRI) showed t2-weighted hyperintense MS plaques in bilateral periventricular white matter and right cerebellar peduncle without diffusion restriction (Figure 3). Gram stain, culture and oligoclonal band were negative in CSF. The patient who was checked for hemogram, sedimentation, C-reactive protein, glucose, liver function tests, kidney function tests, thyroid function tests, immunoglobulins, thrombophilia panel, vitamin D, B12, folic acid, lipid panel, ANA, RF, anti CCP, ferritin, B12 no pathology was detected except for low B12 and low vitamin D levels. The patient, who was diagnosed with multiple sclerosis based on MRI and CSF findings, was given 1 gr iv pulse steroid therapy for 5 days. In the control MRI of the patient, whose complaints passed, 6 months after the first attack of MS, no new plaques were observed, except for stable plaques. The patient reapplied to us for alopecia patches 16 months after she voluntarily discontinued tofacitinib. It was observed that there was no shedding in the hair that had grown after using tofacitinib for 6 months. However, since she still had alopecia patches, it was planned to start methotrexate treatment after neurological evaluation and approval. Informed consent of the patient has been granted.