Azathioprine in combination with methotrexate: a therapeutic alternative in severe and recalcitrant forms of alopecia areata?

Alopecia areata (AA) is a disfiguring autoimmune disease mediated by T lymphocytes targeting hair follicles.1 Its incidence increases almost linearly with age, corresponding to a cumulative lifetime incidence of 2.1%.2 Spontaneous regrowth is possible in patients with limited hair loss, whereas <25% of patients suffering of extensive forms of AA [alopecia totalis (AT)/alopecia universalis (AU) or severe multiple AA (MAA)] experience hair regrowth without any therapy.3 We tested azathioprine (AZA) plus methotrexate (MTX) as a rescue treatment in a group of patients with severe AA for whom a first‐line systemic treatment was ineffective (Table 1). All patients underwent to high‐dose pulsed corticosteroids (HDPCT) followed by MTX, as previously described.4 AZA was added to MTX after at least 6 months of total absence, or cosmetically inacceptable, of hair regrowth. Before starting AZA, thiopurine‐methyltransferase (TPMT) genetic testing was performed.