Background Methotrexate has been used both as an adjunct for low-risk maintenance therapy after initiation with corticosteroids for alopecia areata (AA) and as standalone therapy in some investigations, based on a lack of definitive evidence/guidelines.
Objective To (1) determine the efficacy and risks associated with methotrexate therapy for AA (2) determine differences efficacy of combination with corticosteroids versus standalone treatment, and (3) determine relative efficacy of methotrexate in adult versus pediatric populations.
Methods A systematic review and meta-analysis was performed according to recommended PRISMA guidelines.
Results Methotrexate has reasonable effectiveness in patients with severe AA, and that adults appear to be more responsive to methotrexate treatment compared to pediatric cases. Methotrexate in conjunction with corticosteroids result in higher good/complete response rates compared to those treated with methotrexate alone. A large proportion of recurrence rates occurred in the setting of tapering treatment. Complication rates were acceptable and similar between adults and pediatric cases.
Limitations Studies reviewed were retrospective observational studies with heterogeneity between centers in terms of dosages/protocols for methotrexate use in AA, and adjunctive treatments with a lack of data beyond one year.
Conclusion Methotrexate is an effective monotherapy or adjunct to corticosteroid in the treatment of severe AA.