Two patterns of skin ulceration induced by methotrexate in patients with psoriasis

Lawrence, C.M.; Dahl, M.G.C.

doi:10.1016/s0190-9622(84)70259-3

Cited by 80 publications

(75 citation statements)

References 12 publications

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“…Severe keratinocyte dystrophy was consistently found in the biopsy specimens. The diagnosis of methotrexate toxicity was supported by the similar clinical features to those reported previously [4][5][6][7][9][10][11][12][13][14] and by the blood cell count abnormalities indicating myelotoxicity. Furthermore, no other cause to the mucocutaneous abnormalities was found.…”

Section: Discussionsupporting

confidence: 75%

“…8 In patients with psoriasis, ulcers on psoriatic plaques and on skin unaffected by psoriasis but exhibiting other abnormalities have been described as incipient epidermal necrosis. 10 The skin biopsy specimens obtained from 4 of our 5 patients revealed subtle abnormalities consistent with a direct toxic effect on the epidermis and characterized by severe keratinocyte dystrophy, with unevenly arranged, enlarged keratinocytes containing clear cytoplasm and variably enlarged nuclei, some of which had irregular contours. Multinucleate keratinocytes were visible in a mucosal biopsy specimen from patient 3, who had negative results from the HSV1/2 PCR assay and specific immunohistochemistry, ruling out a viral cytopathogenic effect.…”

Section: Discussionmentioning

confidence: 76%

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Low-dose methotrexate-induced skin toxicity: Keratinocyte dystrophy as a histologic marker

Delyon

Ortonne

Benayoun

et al. 2015

Journal of the American Academy of Dermatology

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Section: Discussionsupporting

confidence: 75%

Section: Discussionmentioning

confidence: 76%

Low-dose methotrexate-induced skin toxicity: Keratinocyte dystrophy as a histologic marker

Delyon

Ortonne

Benayoun

et al. 2015

Journal of the American Academy of Dermatology

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“…3 Cutaneous ulceration within preexisting skin lesions remains an uncommon manifestation of methotrexate toxicity but has been most commonly reported in patients with underlying psoriasis vulgaris. [4][5][6][7][8] These ulcerations may be the initial presenting sign of methotrexate toxicity and can serve as a valuable diagnostic tool for uncovering systemic toxicity. Early lesions may be characterized physically by increased erythema and symptomatically by the development of significant pain.…”

Section: Discussionmentioning

confidence: 99%

Acute Mucocutaneous Methotrexate Toxicity Associated With Interface Dermatitis and Numerous Eosinophils

Ferguson¹,

Asarch²,

VanBeek³

et al. 2013

The American Journal of Dermatopathology

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Acute mucocutaneous methotrexate toxicity is not classically associated with prominent tissue eosinophilia. We present a case of acute methotrexate toxicity associated with pancytopenia and mucocutaneous erosion with interface dermatitis and numerous eosinophils. A 79-year-old male, with a history of psoriasis vulgaris on methotrexate therapy, presented with blisters of the oral mucosa, groin, sacrum, and extremities after daily consumption of methotrexate. Examination revealed blisters and erosions localized to psoriatic plaques, the perineum, and the oral mucosa. Laboratory evaluation demonstrated pancytopenia, megaloblastic anemia, and elevated liver function tests. A skin biopsy of an eroded plaque revealed psoriasiform epidermal hyperplasia with epidermal erosion, parakeratosis, and loss of the granular cell layer. There was an underlying band-like lymphoid infiltrate with interface dermatitis, dyskeratotic keratinocytes, and numerous eosinophils. Direct immunofluorescence studies were negative for the deposition of immunoreactants. Methotrexate was held, and the patient received leucovorin resulting in improvement of blood counts and cutaneous lesions. The histopathologic changes associated with acute mucocutaneous toxicity have been described as pauci-inflammatory erosions associated with dyskeratotic keratinocytes to interface dermatitis with necrotic keratinocytes and occasionally associated eosinophils. Although these changes are most often superimposed on psoriatic plaques, they have been reported to occur on normal skin. Therefore, the differential diagnosis may include lichen planus, a lichenoid drug eruption, or a fixed drug eruption, and given the presence of mucosal ulceration, incipient pemphigus vulgaris or paraneoplastic pemphigus vulgaris. This case illustrates that acute mucocutaneous methotrexate toxicity may be associated with both interface dermatitis and numerous eosinophils.

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“…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. 13,14 It has been reported that patients with multiple co-morbidities, on Weinstein regimen, 15 on self medication or those suffering medical errors have ulceration of psoriatic plaques. 16 Several factors have been identified which can precipitate methotrexate toxicity.…”

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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Two patterns of skin ulceration induced by methotrexate in patients with psoriasis

Cited by 80 publications

References 12 publications

Low-dose methotrexate-induced skin toxicity: Keratinocyte dystrophy as a histologic marker

Low-dose methotrexate-induced skin toxicity: Keratinocyte dystrophy as a histologic marker

Acute Mucocutaneous Methotrexate Toxicity Associated With Interface Dermatitis and Numerous Eosinophils

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

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