MARA rated ruxolitinib cream (Opzelura) B++ (Marginal) before NICE published TA1140 on 17 March 2026. The B++ signal was driven by three decision-critical domains rated structurally weak: HRQoL data were insufficient to confirm a quality-of-life benefit (particularly for patients with Black and Brown skin tones), cost-effectiveness estimates were uncertain despite falling within the NICE acceptable range, and no direct or robust indirect comparison against phototherapy had been established. NICE’s committee reasoning mirrors each of these flagged constraints precisely — HRQoL uncertainty, CE uncertainty, and the inadequate indirect comparison are cited as primary limitations. The conditional recommendation (facial involvement only, after topical failure) reflects a commercial resubmission under a revised pricing arrangement; MARA’s NICE historical signal pointed toward rejection, but the B++ overall grade correctly predicted that the underlying evidence package was viable enough for access to be granted under revised commercial terms.