Mofreh Mansour, Refaat Mohamed, athar mohamed, Mahmoud A. Rageh
Introduction: Alopecia areata (AA) is a chronic, immune‑mediated, non‑scarring hair loss disorder. While intralesional corticosteroids remain first‑line treatment, some patients with recalcitrant AA respond poorly. Microneedling enhances transdermal drug delivery via microchannel formation. Methotrexate, an established systemic immunomodulator, is effective in resistant AA but has been less extensively studied for topical administration. Objectives: To compare the efficacy and safety of methotrexate and triamcinolone acetonide, both delivered via microneedling, in recalcitrant AA. Methods: In this prospective, intra‑individual comparative study, 34 patients with at least two patches of recalcitrant AA received microneedling followed by topical methotrexate (25 mg/mL) on one site and triamcinolone acetonide (5 mg/mL) on a matched site, administered fortnightly for 12 weeks. The primary outcome was the change in Severity of Alopecia Tool (SALT) score. Secondary outcomes included trichoscopic assessment, blinded photographic evaluation, patient satisfaction, and relapse rates at three‑month follow‑up. Safety was assessed at each visit. Results: Both treatment modalities were associated with overall clinical improvement. Methotrexate‑treated areas showed significantly greater reductions in SALT scores (P<0.05), higher levels of patient satisfaction, and lower relapse rates at follow‑up compared to triamcinolone‑treated areas. Both modalities were well tolerated, with only mild, transient adverse effects reported. Conclusions: In this pilot intra-individual study, microneedling-assisted methotrexate appeared to provide superior short-term clinical outcomes to triamcinolone acetonide with an acceptable safety profile in recalcitrant AA. These findings warrant confirmation in larger, adequately powered controlled trials with 6–12-month follow-up to evaluate durability, relapse, and long-term safety.