Background: Methotrexate has been used both as monotherapy and as an adjunct to corticosteroids in the treatment of alopecia areata (AA), though there exists a paucity of definitive evidence and guidelines in this setting.
Objectives: To 1) determine the efficacy and risks associated with methotrexate therapy for AA, 2) determine the differences in efficacy of combination (methotrexate plus corticosteroids) versus stand-alone (methotrexate) treatment, and 3) determine the relative efficacy of methotrexate in adult versus pediatric populations.
Methods: A systematic review and meta-analysis was performed according to recommended PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] guidelines.
Results: Methotrexate has reasonable effectiveness in patients with severe AA; adults appear to be more responsive to methotrexate treatment than pediatric patients. Combination treatment results in a higher complete response rate than methotrexate stand-alone treatment. A large proportion of patients had recurrence in the setting of tapering treatment. Complication rates were acceptable and similar between adult and pediatric patients.
Limitations: The studies reviewed were retrospective observational studies with heterogeneity between centers in terms of methotrexate dosages and protocols in use for AA, and there was a lack of data beyond 1 year for the adjunctive treatments.
Conclusion: Methotrexate is an effective monotherapy or adjunct therapy in combination with corticosteroids in the treatment of severe AA.
Keywords: alopecia; alopecia areata; dermatology; meta-analysis; methotrexate; systematic review.
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