Methotrexate is used in approximately 30% of lichen planopilaris cases unresponsive to hydroxychloroquine, making it one of the most common second-line treatments for this scarring alopecia. Tracking your response to methotrexate is essential because LPP causes permanent follicle destruction, and the difference between effective and ineffective treatment can determine how much hair you ultimately preserve.
This article is for informational purposes only and does not constitute medical advice.
Understanding Lichen Planopilaris and Methotrexate
Lichen planopilaris (LPP) is a form of scarring (cicatricial) alopecia in which inflammation targets the upper portion of hair follicles, eventually destroying them and replacing them with scar tissue. Unlike non-scarring forms of hair loss, hair lost to LPP does not grow back. Treatment focuses on stopping the inflammatory process to preserve remaining hair.
Why Methotrexate Is Prescribed for LPP
Methotrexate is an immunosuppressive and anti-inflammatory medication originally developed for cancer treatment but widely used at lower doses for autoimmune and inflammatory conditions. In LPP, methotrexate reduces the lymphocytic inflammation that attacks hair follicles. It is typically prescribed when first-line treatments (hydroxychloroquine, topical corticosteroids) have not adequately controlled disease activity.
Typical Dosing
Methotrexate for LPP is prescribed at 7.5 to 15mg per week, taken as a single weekly dose (oral or injectable). Folic acid supplementation (1 to 5mg daily, skipping the methotrexate day) is standard to reduce side effects. Your physician will start at a lower dose and increase gradually based on response and tolerance.
Setting Up Your LPP Activity Tracking Protocol
Step 1: Establish a Baseline Before Starting Methotrexate
Your baseline documentation should capture both the extent of permanent damage (scarring areas) and the extent of active disease (inflamed areas where loss is ongoing):
- Scalp photos from five standardized angles under consistent lighting
- Close-up photos of active disease areas showing perifollicular erythema and scale
- AI density measurements from myhairline.ai/analyze for all scalp zones
- Baseline LPP activity score (see below)
- Current symptom severity (itching, burning, tenderness rated 0 to 10)
Step 2: Use an LPP Activity Scoring System
Creating a simple activity score helps you track disease control over time. At each session, rate the following:
| Activity Sign | Score 0 | Score 1 | Score 2 |
|---|---|---|---|
| Perifollicular erythema | Absent | Mild | Moderate to severe |
| Perifollicular scale | Absent | Mild | Moderate to severe |
| Itching/burning/tenderness | None | Mild | Moderate to severe |
| Pull test (gentle tug at margins) | No hairs | 1-2 hairs | 3+ hairs |
| New areas of involvement | None | Possible | Definite |
Total scores range from 0 to 10. A declining trend indicates disease control. A stable high score or increasing score suggests inadequate response.
Step 3: Set Your Monitoring Schedule
| Period | Frequency | Focus |
|---|---|---|
| Weeks 0-12 | Every 4 weeks | Baseline, early response signals |
| Months 3-6 | Every 4-6 weeks | Primary response assessment |
| Months 6-12 | Every 6-8 weeks | Sustained response evaluation |
| Beyond 12 months | Every 8-12 weeks | Long-term maintenance |
What to Expect from Methotrexate Treatment
Response Timeline
Methotrexate typically takes 2 to 3 months to show a meaningful effect on LPP activity. During the first 8 weeks, you may see little change in your activity score or density measurements. This is expected. Full assessment of response usually requires 4 to 6 months of consistent treatment.
Defining Treatment Success in LPP
Because LPP causes permanent scarring, the treatment goal is different from conditions like alopecia areata. Success in LPP means:
- Disease stabilization: No new areas of scarring, no expansion of existing patches
- Reduced activity signs: Less perifollicular erythema and scale at disease margins
- Symptom improvement: Reduced itching, burning, and tenderness
- Stable density: AI density measurements that remain flat (no further decline) over 3 or more consecutive tracking sessions
Regrowth in previously scarred areas is not expected. If you see stable or improving density in zones adjacent to old scarring, that indicates the disease is controlled. For a detailed guide on tracking LPP specifically, see lichen planopilaris tracking.
Tracking for Your Dermatologist
Preparing Appointment-Ready Documentation
Before each dermatology visit, compile your chronological photo series (most recent photos compared with baseline and intermediate sessions), AI density trend graphs by zone, LPP activity score trend over time, a summary of symptoms at each tracking session, and lab results (liver function tests, CBC).
The Importance of Objective Data
LPP progression can be subtle and difficult to assess visually during a brief office visit. Your AI density data provides objective measurements that capture changes too small for the eye to detect in a single appointment but clearly visible in a trend over several months. This data helps your dermatologist make confident decisions about whether to continue, adjust, or change your treatment.
For detailed tips on preparing documentation, see how to document hair loss for your dermatologist.
Liver Monitoring and Safety Tracking
Methotrexate requires regular blood monitoring because it can affect liver function, blood counts, and kidney function.
Required Lab Work
Your physician will typically order the following:
| Test | Frequency | Purpose |
|---|---|---|
| Complete blood count (CBC) | Every 4-8 weeks initially, then every 2-3 months | Monitor for bone marrow suppression |
| Liver function tests (ALT, AST) | Every 4-8 weeks initially, then every 2-3 months | Detect hepatotoxicity |
| Renal function (creatinine) | Baseline and periodically | Monitor kidney function |
| Hepatitis B and C serology | Baseline | Screen before starting |
Side Effects to Log
Common side effects include nausea (often on the day of dosing), fatigue, mouth sores, and gastrointestinal discomfort. Record any side effects in your tracking log with severity (mild, moderate, severe) and whether they resolve between doses. Serious side effects requiring immediate medical attention include persistent cough or shortness of breath, unusual bruising or bleeding, severe mouth ulcers, and signs of infection (fever, chills).
When to Reassess Treatment
Bring your tracking data to your dermatologist for a formal reassessment if your LPP activity score has not decreased after 4 to 6 months, AI density measurements show continued decline despite treatment, side effects are affecting your quality of life, or lab values show concerning trends.
Your objective tracking data transforms this conversation from subjective impressions into a data-supported discussion about next steps, which may include dose adjustment, addition of a complementary treatment, or switching to an alternative immunosuppressant.
Start Tracking Your Methotrexate Response
If you are starting or currently taking methotrexate for LPP, establish your objective baseline today. Upload your scalp photos to myhairline.ai/analyze for zone-by-zone density measurements, begin your LPP activity score log, and build the documentation that helps you and your dermatologist make the best possible treatment decisions.
This article is for informational purposes only and does not constitute medical advice. Methotrexate requires prescribing and monitoring by a qualified physician. Always consult your dermatologist before starting or changing any treatment.