Utility of azathioprine, methotrexate and cyclosporine as steroid-sparing agents in chronic alopecia areata: a retrospective study of continuation rates in 138 patients.

BACKGROUND

The management of chronic alopecia areata (CAA) is challenging. There is currently no therapy that produces consistent successful hair regrowth. Systemic therapies, including prednisolone and steroid-sparing agents (SSA), are often tried in patients with CAA. As there are no head-to-head clinical trials that compare efficacy of one SSA over another, retrospective studies of treatment in clinical practice may help guide clinical practice.

OBJECTIVE

To investigate the utility of SSAs in the treatment of AA.

METHODS

An electronic medical records search identified patients with AA and those prescribed azathioprine, cyclosporine or methotrexate between 2002 and 2019. Type of AA, treatment duration, reason for cessation, use of concurrent prednisolone, dose of prednisolone and duration of prednisolone use were recorded. The primary outcome was SSA continuation rate at 6 and 12 months.

RESULTS

A total of 852 AA patients were identified, among whom 138 patients had been treated with azathioprine, methotrexate or cyclosporine. Of these 138 patients treated with a SSA, 92 (66.7%) continued treatment for at least 12 months: 75.3% (55/73) of azathioprine users, 50% (11/22) of methotrexate users and 60.5% (26/43) of cyclosporine users. At 12 months, 67.3% of azathioprine users required concurrent prednisolone at a mean dose of 5.6 mg daily, 63.6% of methotrexate users required prednisolone at a mean dose of 5 mg daily and 57.7% of cyclosporine users required prednisolone at a mean dose of 8.7 mg daily. The SSA was ceased due to an adverse event in 15.9% of patients and a lack of efficacy in 17.4%.

CONCLUSION

The most well-utilized SSA for CAA patients at our clinic was azathioprine. This study highlights that most CAA patients who commence treatment with azathioprine, methotrexate or cyclosporine continue that treatment for at least 12 months and most require concurrent low-dose prednisolone to maintain remission or promote continued hair regrowth.