Erosion of psoriatic plaques: An early sign of methotrexate toxicity

Pearce, Hannah P.; Wilson, Barbara B.

doi:10.1016/s0190-9622(96)90097-3

Cited by 83 publications

(84 citation statements)

References 38 publications

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“…Type 1 involves the painful erosion of psoriatic plaques which can take place shortly after initiation of the treatment or in the setting of dose alteration and drug interaction. 10 This can be mistaken as an exacerbation of the condition itself. Type 2 describes ulceration in diseased skin, which has a variable correlation with treatment duration and thus may be overlooked as evidence of methotrexate toxicity.…”

Section: S23mentioning

confidence: 99%

“…The most common risk factors are an alteration in methotrexate dosage and the use of non-steroidal anti-inflammatory drugs. 10 Other possible contributing factors are renal insufficiency, advanced age, lack of folate supplementation, methotrexate dosing errors, hypoalbuminemia, infection, pustular flare of psoriasis, greater than moderate alcohol intake and drug interaction. 17 Reduced doses of methotrexate are effective in controlling psoriasis in the elderly, probably as a consequence of decreased renal clearance.…”

Section: S23mentioning

confidence: 99%

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An unusual case of acute methotrexate toxicity manifesting as ulcers on psoriatic plaques in an elderly male

Singh¹,

Chatterjee²,

Banerjee

et al. 2015

Medical Journal Armed Forces India

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Section: S23mentioning

confidence: 99%

Section: S23mentioning

confidence: 99%

An unusual case of acute methotrexate toxicity manifesting as ulcers on psoriatic plaques in an elderly male

Singh¹,

Chatterjee²,

Banerjee

et al. 2015

Medical Journal Armed Forces India

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“…Methotrexate (MTX) is an effective but potentially toxic antimetabolite anticancer drug which has been in use since 1960s (1,2). Low-dose MTX therapy used in psoriasis rarely causes toxicity (3).…”

Section: Introductionmentioning

confidence: 99%

A case of Severe Low-dose Methotrexate-induced Toxicity

Demir¹,

Tezcan²,

Türkoğlu³

et al. 2016

Haseki

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“…Recognised signs of toxicity include bone marrow suppression, hepatotoxicity and oral/gastrointestinal ulcerations [1]. In psoriatic patients treated with methotrexate, erosions within psoriatic plaques are a well-documented sign of systemic methotrexate toxicity, often alongside such other features as macrocytosis and mucosal ulceration [2]. Cutaneous erosions are more common in patients over 55 years, particularly following dose alterations [2].…”

Section: Introductionmentioning

confidence: 99%

Cutaneous Erosions: An Under-Recognised and Rare Side Effect of Methotrexate Treatment, in the Absence of Systemic Methotrexate Toxicity

Felton¹,

Al‐Niaimi²

2012

J Clin Exp Ophthalmol

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Methotrexate is a potentially toxic anti-folate drug widely used in the treatment of skin disease. We describe here a case of cutaneous erosions occurring in previously erythrodermic skin after only four weeks of very low-dose therapy, in the absence of features of systemic methotrexate toxicity. We thus report that localised cutaneous toxicity can occur in isolation, and propose that cutaneous erosions be considered a rare but potentially serious side effect of methotrexate, rather than a sign of actual or impending systemic toxicity.Methotrexate toxicity was suspected but a tablet-count confirmed that there had not been an accidental overdose and indeed, when processed, her serum methotrexate levels were very low. This demonstrates the benefit of having prescribed methotrexate tablets of one only strength (i.e. 2.5 milligrams) [6]. Histology showed a large area of epidermal ulceration, with occasional apoptotic keratinocytes and evidence of re-epithelialisation.There had been no recent change to her medications and she had not taken any over-the-counter drugs. Apart from aspirin, none of her medications interacted with methotrexate: Whilst aspirin may displace methotrexate from its plasma protein binding-sites and/or competitively inhibit its renal tubular secretion, [3] any such actions would be expected to have increased the serum levels. Our patient responded well to cessation of methotrexate therapy and application of topical steroids, with complete resolution in 2 weeks. DiscussionThis patient presented with cutaneous erosions suggestive of methotrexate toxicity but without gastrointestinal upset, significant bone marrow suppression or renal/hepatic dysfunction. Additionally, impending systemic toxicity would not be expected from such a short duration of low-dose therapy, and this was reflected by the low methotrexate level.Citation: Felton SJ, Niaimi FA, Ferguson JE (2012) Cutaneous Erosions: An Under-Recognised and Rare Side Effect of Methotrexate Treatment, in the Absence of Systemic Methotrexate Toxicity. J Clin ExpThe lesions seen were more consistent with type I ulceration due to their early onset and rapid healing after methotrexate withdrawal but they did not develop within psoriatic plaques as would be expected, rather they developed in previously erythrodermic skin, overlapping between types I and II. We wish to highlight this side effect of methotrexate as ersosions may be misdiagnosed as deterioration of the underlying psoriasis, prompting an increase of methotrexate dosage, which could worsen symptoms.We suggest that the erosions occurred in consequence of a direct toxic effect of methotrexate on keratinocytes, [5,7] Keratinocytes may sequester methotrexate, and with rapid cell turnover, more epidermal cells are thus in the S-phase of the cell cycle where methotrexate exerts its effects [8], so leading to local skin toxicity. Therefore we conclude that our patient was more susceptible to localized skin toxicity due to her preceding erythroderma.

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Erosion of psoriatic plaques: An early sign of methotrexate toxicity

Cited by 83 publications

References 38 publications

An unusual case of acute methotrexate toxicity manifesting as ulcers on psoriatic plaques in an elderly male

An unusual case of acute methotrexate toxicity manifesting as ulcers on psoriatic plaques in an elderly male

A case of Severe Low-dose Methotrexate-induced Toxicity

Cutaneous Erosions: An Under-Recognised and Rare Side Effect of Methotrexate Treatment, in the Absence of Systemic Methotrexate Toxicity

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