Systemic Methotrexate Treatment in Childhood Psoriasis: Further Experience in 24 Children from India

Abstract

Well-designed studies on systemic therapeutic modalities for severe psoriasis in children are rare. Children with severe disease are treated with the support of data extrapolated from that in adult, although management in them differs from adults in several important aspects. Like other systemic modalities, data regarding the use of methotrexate in the treatment of childhood psoriasis is meager. This study aims to analyze the efficacy and safety of methotrexate in severe or disabling childhood psoriasis. The records of all the patients <18 years of age treated with systemic methotrexate at the psoriasis clinic of our institute from January 1993 to December 2006 were retrieved. Information regarding demographic profile, disease characteristics, response to treatment, side effects, etc. was noted from predesigned clinic proforma. Indications of methotrexate use were baseline psoriasis area and severity index (PASI) >10, disease refractory to conventional therapies and disabling psoriasis even though the psoriasis area and severity index was <10. Clinical status of patients was assessed at weekly intervals for the first 2 weeks, fortnightly during next month and then monthly. Response to therapy was graded as good (50-75% decrease in PASI) and excellent (>75% decrease in PASI). Laboratory investigations to detect methotrexate induced toxicity were performed at regular intervals. Of the 29 patients treated with methotrexate, 24 were eligible for the final data analysis. Indication for the institution of methotrexate therapy was severe disease, viz., extensive recalcitrant plaque type psoriasis in 17 patients, erythroderma and generalized pustular psoriasis of von-Zumbusch type in three patients each and severe disabling palmo-plantar involvement along with chronic plaque lesions in one patient. Response to therapy was excellent (>75% decrease in PASI) in all but two patients. The mean time to control the disease, i.e., 50% reduction in PASI was 5.1 weeks. Mean total cumulative dose of methotrexate in the first episode was 215 mg. The duration of remission could be calculated in nine patients only, varying from 1.5 months to 3 years. Side effects were mild, observed in nine children, which included nausea, vomiting, and loss of appetite. Methotrexate is an effective, cheap, easily available, and reasonably safe drug to be used in severe childhood psoriasis under an expert supervision and laboratory monitoring.

Pediatric Psoriasis

“…Methotrexate is also the drug of choice for patients with psoriatic arthritis in addition to skin disease [ 79 ]. Methotrexate is associated with a >75 % improvement in PASI score [ 80 ]. Dosages used range from 0.2 to 0.7 mg/kg per week [ 79 -81 ].…”

Kinder und Jugendliche mit Psoriasis

“…Der humane Anti-IL12/23-Antikörper Uste- kinumab (Stelara®) wird aktuell in einer klinischen Studie bei Kindern älter als 12 Jahre untersucht. Methotrexat wird in einer Dosis von 5-10 (−15) mg 1-mal pro Woche (0,2 mg/kg KG) appliziert, angesichts der häufigen Abwehr von Injektionen durch die Kinder trotz der wechselhaften intestinalen Resorption eher oral [15,23,31,36]. Die initial erforderlichen Laborkontrollen von Blutbild, Leber-und Nierenparameter in 2-, dann 4-wöchentli-chen Abständen sind sicherlich gerade für Kinder einschränkend und daher häufig therapielimitierend.…”

Childhood Psoriasis

“…Literatürde püstüler, eritrodermik ve dirençli plak tip psöriazisli çocuk hastalarda Mtx kullanımını bildiren olgu raporları ile birlikte, 13 ve 24 çocuk hastayı içeren iki önemli olgu serisi mevcuttur [54][55][56][57][58] . Çocuklarda Mtx kullanım protokolünü ve yan etkilerini takip etmek amacıyla yayınlanmış herhangi bir rehber olmamakla beraber tedavinin ilk ayında haftalık sonrasında ise her 4-6 haftada bir karaciğer fonksiyon testleri, BUN, kreatinin ve tam kan sayımı yapılması kabul gören bir yaklaşımdır.…”