BACKGROUND: Alopecia areata (AA) is an autoimmune hair disorder, with the clinical variants ophiasis and extensive variants AA totalis and universalis, having poor response to therapy. Oral steroids are used to treat the severe variants, requiring prolonged therapy, which leads to side effects while discontinuation leads to high relapse rate. Azathioprine is a steroid-sparing agent for the severe AA forms.

OBJECTIVE: To review the current evidence on the therapeutic efficacy and adverse effects of azathioprine for severe forms of alopecia areata

METHODS: Published articles utilizing azathioprine for alopecia areata were obtained until July 2018 from PubMed, MEDLINE, Cochrane Library, TRIP database, HERDIN, and Google Scholar.

RESULTS: Seven articles underwent a full-length review. Clinical variants include patchy, diffuse, steroid-resistant, reticulate, totalis, universalis, ophiasis, and sisaipho. Doses ranged from 2 to 2.5 mg/kg/day or weekly 5 mg/kg pulse therapy. Initial response ranged from 6 to 12 weeks, with almost complete resolution by 32 weeks. Response was sustained for 6 months upon discontinuation, with only 14% relapsing at 2.5 months. Adverse effects were gastrointestinal discomfort, elevated liver function tests, and myelosuppression.

CONCLUSION: There is emerging evidence on the efficacy and safety of azathioprine for the treatment of extensive forms of alopecia areata. Randomized-controlled trials are needed to evaluate its efficacy.