Intralesional Triamcinolone Maintains Efficacy Over Methotrexate for Localized Alopecia Areata

Intralesional triamcinolone (TrA) led to better outcomes in treating localized alopecia areata (AA) than methotrexate (MTX), both in terms of hair regrowth and patient satisfaction in new findings from a head-to-head trial.1

“Comparing the effectiveness of intralesional MTX and TrA in treating AA offers valuable insights for dermatologists when treating focal AA. Intralesional corticosteroids are generally accepted as first‐line treatment but may not be an option for all patients because of contraindications or side effects. Investigating alternative therapies such as MTX may help offer a steroid‐sparing treatment for steroid‐intolerant or nonresponsive patients2,” lead investigator Narges Ghandi, MD, associate professor of dermatology, Autoimmune Bullous Diseases Research Center and Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran, and colleagues wrote.1

Ghandi and colleagues evaluated 40 participants with localized AA that received either TrA (n = 20) or MTX injections (n = 20) once a month for 3 months. They evaluated scores on Severity of Alopecia Tool (SALT) over 6 months and also document trichoscopic findings, adverse effects, and satisfaction with treatment. Participants were mostly male (n = 31; 77.5%) and had an average age of 34.9 years (standard deviation, 10.5; TrA, 34 years [SD, 10.5]; MTX, 35.9 years [10.6]). The TrA group was 70% male n = 14) and 30% female (n = 6) and the MTX group was 85% male (n = 17) and 15% female (n = 3). The TrA group had an average disease duration of 2.4 years (SD, 1.2) and the MTX group had an average disease duration of 2.7 years (SD, 2.2).1

The TrA group had a mean SALT score of 12 (SD, 3.34) before treatment, with a median of 10.5 and an interquartile range (IQR) of 5 and the MTX group had a higher mean baseline SALT score of 14.6 (SD, 3.56), with a median of 15 and an IQR of 7.75.

The investigators found that participants that received TrA showed strong improvements, with their SALT scores dropping by an average of 54.36% (SD, 28.7), indicating significant hair regrowth. In contrast, participants that received MTX had scores worsen by 54.6% (SD, 77.9) indicating a significant increase in hair loss. The change in SALT scores was significant in both the TrA group (P = .001) and the MTX group (P = .006).1 Additionally, both groups demonstrated improvements in trichoscopic changes, but only the reduction in black dots in the MTX group was statistically significant.

In terms of safety, adverse events were uncommon and included erythema (n = 3; 15% in each group) and hypopigmentation (n = 1; 5% in the MTX group). Overall, participants who received TrA gave a much higher satisfaction score of 7.1 out of 10 (SD, 2.2) compared to 4.9 (SD, 1.9) in the MTX group (P <.05).1

Ghandi ad colleagues recognized several limitations of the study. The small sample size (20 patients per group) reduced statistical power and generalizability, highlighting the need for larger multicenter studies. The absence of a placebo control limited the ability to distinguish treatment effects from the natural course of AA. Wide variability in the MTX group, shown by the large SD in SALT score improvement, indicated a mixed response profile, and future work should investigate patient-specific factors influencing outcomes. Furthermore, the 6-month follow-up may be too short to assess long-term efficacy and relapse, requiring extended studies. Performance bias was also possible since the treating physician was not blinded; although injections were standardized by an experienced dermatologist, unconscious influence cannot be fully excluded. While outcome assessment was blinded, blinding effectiveness was not evaluated, potentially affecting internal validity. Finally, although trichoscopic findings such as persistent white dots in the MTX group and exclamation mark hairs in the TrA group were observed, their diagnostic or prognostic value was not assessed, warranting further study.

“Our results highlight the potential efficacy of intralesional TrA in managing AA, while suggesting that the efficacy of intralesional MTX monotherapy may be inconsistent and less reliable as a treatment option for AA. Additional research is needed to assess the true efficacy of intralesional MTX in larger patient populations with extended follow‐up periods, as well as to determine the most effective treatment regimen for this medication,” Ghandi and colleagues concluded.1

References

1. Ghandi N, Rashidi A, Saberi F, Abedini R, Tootoonchi N, Babaie H. Is Intralesional Methotrexate an Effective Alternative to Intralesional Triamcinolone in Alopecia Areata? Findings From a Randomized Controlled Trial. J Cosmet Dermatol. 2025;24(8):e70367. doi:10.1111/jocd.70367

2. Elsaie ML, Hasan MS. Successful treatment of long-standing alopecia totalis with intralesional methotrexate. J Cosmet Dermatol. 2022;21(2):855-856. doi:10.1111/jocd.14117