MTX en AA

Oral Methotrexate Monotherapy for Severe Alopecia Areata

TAKE-HOME MESSAGE

• In this retrospective review, 15 adults and children with severe alopecia areata refractory to other therapies were treated with oral methotrexate monotherapy. Improvement was observed in 13 patients, all of whom demonstrated maximal improvement within the first year of therapy. Nausea was reported by 2, but none discontinued therapy due to side effects. No laboratory abnormalities were observed in the short term but long-term laboratory follow-up was not available.

• Oral methotrexate may be an effective and accessible treatment option for severe alopecia areata patients, but larger prospective trials are needed to verify these results.

–  Margaret Hammond, MD

Written by

Amos Gilhar MD

Alopecia areata (AA) negatively affects quality of life and may lead to psychological disorders. However, treatment of AA remains challenging. The reasons for this are that topical treatments are largely unsuitable for severe AA, whereas long-term systemic treatment has problematic safety profiles and rapid relapse. Therefore, significant unmet needs exist in the treatment of AA. 

The aim of the Kinoshita-Ise study was to determining the efficacy and risk of MTX as a monotherapy in AA. A total of 15 severe AA patients were included in the study, among them 9 males and 6 females; 8 patients were under the age of 18 years. The results of the study demonstrated complete hair regrowth in 13 patients after 1 year of treatment, without major side effects, indicating that MTX monotherapy may serve as an optional therapy for severe AA patients. However, the small number of patients did not allow us to assess fully the benefits and risks of MTX treatment in pediatric patients and adults following long-term MTX treatment, as well as the treatment's efficacy in the different types of AA, in gender, and in different ages of onset.

Furthermore, there is no control group in this study that includes MTX monotherapy combined with corticosteroids. MTX has been used as monotherapy and an adjuvant to corticosteroids, so it's quite crucial to compare the efficacy of both modes of treatment. 

According to previous publications and the current one, it appears that MTX monotherapy is reasonably effective in treating severe AA. However, the recently revealed therapeutic potential of JAK inhibitors in AA management created a huge buzz worldwide and raised hope for a breakthrough in treating AA. JAK inhibitors, just like other systemic treatments for AA, might also have increased the risk of malignancy and infections as they inhibit important immunosurveillance mechanisms. Therefore, it is urgent to identify and explore additional therapeutic targets for AA immunotherapy.

Abstract

BACKGROUND

Although several therapeutic options have been suggested for alopecia areata (AA), none of them are consistently effective, thus making the management of severe or refractory cases challenging. Several studies have recently reported the usage of methotrexate (MTX) in AA; however, the pure effect of MTX monotherapy remains elusive.

OBJECTIVE

To evaluate efficacy and safety of oral methotrexate monotherapy for AA.

METHODS

We retrospectively reviewed the clinical course of AA patients including pediatric cases treated with MTX monotherapy. Their detailed clinical data including original severity of AA, final treatment outcome, the duration until the maximum response, and side effects, were assessed. Statistical analysis was performed to evaluate if the clinical factors including the duration of current alopecia, age, the presence of body hair loss, and sex were associated with treatment response.

RESULTS

All included patients had severe AA and failed standard therapies. Thirteen out of 15 cases demonstrated improvement during the monotherapy, and all responders demonstrated the maximum response within 1 year. Female patients had significantly better outcomes than male patients. Other factors did not significantly influence on the treatment outcome. None of the patients experienced side effects that were severe enough to terminate the treatment.

CONCLUSIONS

Our results support MTX monotherapy as a feasible option for severe AA patients who fail other standard therapies or for whom systemic corticosteroids are contraindicated.

Journal of cutaneous medicine and surgery

Oral Methotrexate Monotherapy for Severe Alopecia Areata: A Single Center Retrospective Case Series

J Cutan Med Surg 2021 Mar 09;[EPub Ahead of Print], M Kinoshita-Ise, M Sachdeva, SA Martinez-Cabriales, NH Shear, P Lansang