Methotrexate Treatment for Alopecia Areata with Greater than 50% Involvement

Alopecia areata is a non-scarring alopecia that can present as patches of hair loss (areata, AA), complete scalp hair loss (totalis, AT) or complete scalp and body hair loss (universalis, AU). It is an autoimmune disease mediated via CD8+ T-cell activation and NKG28 signaling targeting the hair bulb. Previous reports indicate that systemic treatment with methotrexate (MTX) benefits patients with AT or AU when used alone or with systemic corticosteroid administration . This study evaluates the utilization of MTX as a treatment modality in patients with alopecia areata who have greater than 50% hair loss.

             Methotrexate appears to be an effective short-term treatment option for patients with AA, including AA-ophiasis type, showing an overall 71% response rate, of which 36% of treated patients had complete re-growth . Hair regrowth occurred in 1-3 months with complete hair growth seen from 6-18 months, suggesting treatment with MTX should continue until an 18 month endpoint unless complete response is observed beforehand. An initial 21-day prednisone taper with MTX did not enhance hair regrowth and may be unnecessary. Unfortunately, almost every complete responder relapsed when MTX was discontinued or when the dose was tapered.

                An IRB-approved retrospective chart review of patients selected with the ICD-9 code for AA seen at the University of Pittsburgh Department of Dermatology from 2009-2011 was performed. Charts were individually reviewed for an established diagnosis of AA, AT, or AU. Patients were selected who had been evaluated to have >50% scalp alopecia and subsequently treated with MTX(15-20 mg per week) with or without an initial 1 mg/kg/day, 21 day, oral prednisone taper. The elements of the medical record that was extracted included: age, gender, alopecia type (AA/AT/AU), time to clinical hair regrowth, time to complete (cosmetically acceptable) hair regrowth, and time to relapse.

           Alopecia areata is a non-scarring alopecia that can present as patches of hair loss (areata, AA), complete scalp hair loss (totalis, AT) or complete scalp and body hair loss (universalis, AU). It is an autoimmune disease mediated via CD8+ T-cell activation and NKG28 signaling targeting the hair bulb. Previous reports indicate that systemic treatment with methotrexate (MTX) benefits patients with AT or AU when used alone or with systemic corticosteroid administration]. This study establishes that  the utilization of MTX as a treatment modality in patients with alopecia areata who have greater than 50% hair loss.