Efficacy and Safety of Low-Dose Methotrexate in Pediatric Refractory Alopecia Areata: A Retrospective Case Series

Abstract

Alopecia areata (AA) is a chronic autoimmune disorder causing non-scarring hair loss, with a significant psychosocial impact,
particularly in pediatric patients with severe, refractory forms. While various treatments exist, effective and well-tolerated
options for this population remain a clinical challenge. This study aimed to evaluate the safety and effectiveness of low-dose
methotrexate (MTX) in pediatric patients with refractory AA.
This retrospective case series included 24 pediatric patients (11 males, 13 females; mean age 9.1 ± 4.5 years) with severe refrac
tory AA. Patients received oral MTX (0.4 mg/kg weekly, with folic acid supplementation), 9 children were given dexamethasone
0.1mg in mini oral pulse at the Dermatology Department of Tripoli Central Hospital and a private clinic from December 2021
to January 2024. Hair regrowth was categorized as good (>75% regrowth), moderate (50-75% regrowth), little (<50% regrowth),
or no response. Recurrence rates and adverse effects, including liver enzyme levels, were documented.
Of the 24 patients, 5 missed follow-up appointments. Among the 19 patients who completed treatment and follow-up, 16
(84.2%) experienced good to moderate hair regrowth. The recurrence rate among the 19 patients who completed follow-up was
31.6% (6 patients). Minimal adverse effects were observed, with only one patient showing a mild increase in aspartate transami
nase (AST) levels. The study population included various forms of alopecia, with 41.7% having AA and 58.3% having Alopecia
universalis (AU). Associated conditions included low ferritin levels (25%) and hypothyroidism (12.5%).
Low-dose methotrexate appears to be a generally effective and well-tolerated treatment option for pediatric patients with severe
refractory Alopecia areata. These findings suggest MTX can induce significant hair regrowth with a low incidence of adverse
events. Further research with larger sample sizes, standardized outcome measures, and longer follow-up periods, ideally in pro
spective studies with control groups, is warranted to confirm these results and explore long-term outcomes.