Methotrexate and etretinate as concurrent therapies in severe psoriasis

Abstract

A patient with pustular psoriasis, which was inadequately controlled by high-dose methotrexate and potent topical corticosteroid therapy, was treated with oral methotrexate and the aromatic retinoid etretinate. The patient's psoriasis improved with sustained maximal etretinate therapy and continued high-dose methotrexate therapy. Subsequently, the methotrexate dose was tapered and used of this drug was discontinued. Previously unattainable success in controlling the psoriasis was achieved with continued etretinate treatment. There were no recognizable adverse effects from concurrent therapy. As the methotrexate dose was tapered, the patient noted increased psoriatic arthritic pain, unrelieved at maximal etretinate levels, but improved with indomethacin treatment. Combination therapy with methotrexate and etretinate may be useful in the treatment of severe psoriasis by providing a controlled transition from methotrexate to etretinate therapy alone.

Combination therapy to treat moderate to severe psoriasis

“…Although no controlled studies have been performed, anecdotal reports have been published of the combination's success in recalcitrant cases with no increase in liver toxicity noted. 69,70 That mirrors the experience of the authors.…”

Etretinate Therapy in Generalized Pustular Psoriasis (Zumbusch Type)

“…This is in con trast to methotrexate, which in some pa tients becomes less effective after prolonged administration [6]. Such a resistance has been observed in 2 patients in whom metho trexate, after about 6 months of application, did not prevent recurrences.…”

British Association of Dermatologists guidelines on the efficacy and use of acitretin in dermatology

“…39,40 This has been based on anecdotal evidence extrapolated from etretinate. 41 Although this combination can be very effective, sporadic severe hepatotoxic responses have been reported. [42][43][44] The efficacy of concomitant use of acitretin with ciclosporin is not convincing 45 and, in addition, this combination carries the risk of accumulation of ciclosporin as both drugs are inactivated by the same cytochrome P-450 system.…”