A Practical Approach to the Use of Methotrexate

Abstract

Background Methotrexate is approved by the Food and Drug Ad ministration for the treatment of severe, recalcitrant, and disabling psoriasis that is not adequately responsive to other forms of therapy. It is a systemic immunosuppressant that requires appropriate patient selection, screening laboratory values, and close monitoring before initiation of a maintenance regimen. Purpose This clinical review outlines a practical approach for the use of methotrexate in psoriasis. Methods A review of English-language literature between 1950 and 2010 was conducted, and the results are presented here. Results With close monitoring and appropriate patient selection, methotrexate is often an effective treatment option for moderate to severe psoriasis. Attention to individual patient risk factors and understanding of dosing regimens, contraindications, and “black box” warnings regarding methotrexate use can assist dermatologists in safely prescribing methotrexate for psoriasis treatment. Limitations This practical approach is based on an extensive literature review and the National Psoriasis Foundation and American Academy of Dermatology guidelines formulated after years of clinical practice, newer efficacy trials, and expert consensus regarding management in psoriasis patients. We have additionally incorporated some recommendations from our clinical experience at the University of California-San Francisco Psoriasis Treatment Center as indicated in the text. As always, clinical judgment and risk assessment should be used in selecting appropriate psoriasis patients for methotrexate therapy. Conclusion Methotrexate remains an effective, less expensive, and safe option for psoriasis patients who were previously unresponsive to other forms of therapy.