Background: Alopecia areata is one of the most common human autoimmune disorders and its severe types are refractory to all conventional therapies. Corticosteroids have been used in severe alopecia areata since 1950s but there is concern over complications caused by high doses of corticosteroids. Methotrexate has been used as an adjunctive therapy in some autoimmune disorders and has been proposed to be effective in the treatment of severe alopecia areata both as a monotherapy and in combination with corticosteroids. Methods: In this study, 120 patients of intractable alopecia areata totalis and universalis with a mean duration of 3.27 ±1.60 years were studied. We treated them with methotrexate in combination with intravenous and low dose of prednisolone for one year. Methotrexate 10 mg per week was administered in combination with three monthly methylprednisolone and oral prednisolone 15 mg per day for one year. Response to the treatment was evaluated clinically and by serial photographs. Results: Sixty four patients (57.7%) gained total hair regrowth after treatment with no significant difference between alopecia totalis and universalis. Almost half of the patients (44.75%) remained disease free until the end of the one-year follow-up. Relapse occurred in 34 patients (56.25%); of them 20% were focal relapses. Nine patients out of 120 patients (7.5%) experienced severe adverse effects of the therapy. Conclusion: Our study suggested that methotrexate could be used as a safe and well tolerated adjunctive therapy for severe alopecia areata although careful monitoring of adverse effect is necessary. Furthermore, controlled prospective clinical trials are warranted to answer many of the questions regarding methotrexate therapy for severe alopecia areata.