Is methotrexate an effective and safe treatment for maintaining hair regrowth in people with alopecia totalis? A Critically Appraised Topic.

CLINICAL QUESTION/SCENARIO: Is methotrexate (MTX) an effective and safe treatment for maintaining hair regrowth in people with alopecia totalis?

BACKGROUND: Alopecia areata (AA) is a common disorder causing nonscarring hair loss with an estimated lifetime prevalence of approximately 2%. Treatment of extensive AA is challenging. The aim of this Critically Appraised Topic was to assess the current evidence regarding use of MTX for inducing and maintaining hair growth in patients with alopecia totalis.

METHODS: We critically appraised the literature identified from searching PubMed, Ovid MEDLINE, Ovid Embase and Cochrane Central (October 2017), using the search terms ("alopecia areata" OR "alopecia totalis" OR "alopecia universalis") AND (methotrexate).

RESULTS/IDENTIFIED EVIDENCE: Two prospective studies and 11 retrospective case series were included, comprising 226 patients with alopecia varying from 30% hair loss to alopecia universalis at baseline. MTX was usually given with systemic corticosteroids for induction of hair regrowth rather than regrowth maintenance. Regrowth, defined as anything from 50% to complete regrowth, was reported in 20-90% of patients. Relapse occurred in 20-80%, with variable regrowth on retreatment. Most series were small, with limited methodological detail and follow-up data. Adverse effects ranged from 7% to 60%.

DISCUSSION AND RECOMMENDATION FOR CLINICAL CASE: We found insufficient evidence to conclude whether MTX is useful for maintaining regrowth in extensive AA. We found some evidence to suggest that hair regrowth may be induced by MTX when used in combination with systemic corticosteroids, but it was difficult to attribute responses to any one treatment or spontaneous regrowth. Included case series were at a high risk of bias. Randomized controlled trials are needed to evaluate whether MTX alone, or in combination with corticosteroids, vs. placebo is useful for inducing and/or maintaining remission of hair regrowth. In the meantime, MTX may occasionally be considered in people with severe disease that significantly impacts on their quality of life.