Pediatric alopecia universalis with poliosis post-psychosocial stress: a case report on methotrexate and adjunctive management.

Alopecia areata (AA) is an immune-mediated non-scarring hair loss disorder. Severe forms, including alopecia totalis and alopecia universalis (AU), are rare in children and often refractory. Psychosocial stress has been implicated as a trigger, and pigmentary changes may occur during regrowth. We report a 9-year-old girl from Honduras with AU involving the scalp, eyebrows, eyelashes, and forearms, with nail pitting following a significant psychosocial stressor. Laboratory studies showed normal thyroid function and low vitamin D levels. Initial treatment included topical clobetasol propionate 0.05% for 6 months, topical minoxidil 5% for 12 months, and oral vitamin D supplementation for 6 months, with minimal response. Systemic therapy was initiated with oral corticosteroids (1 mg/kg/day) tapered over 4 months, followed by oral methotrexate (12 mg/m²/week) for 1 year; topical therapies were maintained concurrently throughout systemic treatment. Hair regrowth began at 3 months of methotrexate, initially as diffuse poliosis, followed by complete terminal hair regrowth and normalization of nail changes. Psychological support was provided throughout management. This case highlights psychosocial stress as a potential contributor in pediatric AU and supports a multidisciplinary approach. Methotrexate was effective and well tolerated, and poliosis may be a marker of follicular recovery.