METHOTREXATE TREATMENT FOR SEVERE ATOPIC DERMATITIS PATIENTS WITH PERSISTENT KERATOCONJUNCTIVITIS ASSOCIATED WITH DUPILUMAB

Abstract

<h3>Introduction</h3> Severe atopic dermatitis (AD) in adults, unresponsive to topical medications, may require treatment with anti-IL4/IL13 biologics or JAK inhibitors. We report two severe AD patients intolerant to dupilumab successfully treated with low dose methotrexate (MTX). <h3>Case Description</h3> Case 1: A 21-year-old F with atopy (IgE 3,500 IU/L) and allergic rhinitis, presents with uncontrolled chronic AD, non-responsive to emollients, topical corticosteroids, oral cyclosporin and intermittent prednisone. Due to persistent AD and treatment related atopic keratoconjunctivitis, dupilumab was discontinued after two years. MTX 12.5 mg p.o. weekly was begun with marked resolution in eczema and pruritus and resolution of eye symptoms for the past 11 months. Case 2: 23-year-old M with history of asthma, seasonal allergies, and chronic severe AD non-responsive to emollients, bleach baths, topical steroids, topical calcineurin inhibitors, and phototherapy. At age 17, dupilumab was initiated with complete and sustained control of AD. Due to progressive keratoconjunctivitis and nodular degeneration of the cornea, dupilumab was discontinued after 5 years of treatment. MTX 10 mg q1wk was begun with good response at 2 months. <h3>Discussion</h3> Low dose methotrexate can be an alternative add-on treatment for severe AD in patients unresponsive or intolerant to biologics or JAK inhibitors. Use of methotrexate has been reported to be effective and safe in small uncontrolled studies of patients with severe AD. However, its comparative efficacy with biologics, cyclosporin, or JAK inhibitors has not been assessed.