Abstract
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.
Highlights
Methotrexate is a potentially toxic anti-metabolite and anti-folate chemotherapy drug that is frequently used in the treatment of psoriasis and other skin disorders
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]
Our patient responded well to cessation of methotrexate therapy and application of topical steroids, with complete resolution in 2 weeks. This patient presented with cutaneous erosions suggestive of methotrexate toxicity but without gastrointestinal upset, significant bone marrow suppression or renal/hepatic dysfunction
Summary
Methotrexate is a potentially toxic anti-metabolite and anti-folate chemotherapy drug that is frequently used in the treatment of psoriasis and other skin disorders. In 1984, Lawrence and Dahl described two types of methotrexateinduced skin ulceration in psoriatic patients, [5] in type I ulceration, psoriatic plaques became painful and eroded shortly after starting methotrexate or restarting following a treatment-break (median time-period 10 days). Healing time after cessation of treatment was much longer (median 9 weeks; longer than 2 years in one patient). The objective of this case report is to describe the occurrence of cutaneous erosions as a rare but potentially serious side effect of methotrexate in the absence of features of systemic toxicity including a high serum methotrexate level
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