The use of mycophenolate mofetil in psoriasis: An educational article and expert opinion

Abstract

Background: Patients with mild psoriasis are generally treated with topical medications including corticosteroids, coal tar, anthralin (Dithranol), salicylic acid, vitamin D analogues such as calcipotriol, retinoid such as tazarotene, and calcineurin inhibitors such as pimecrolimus. The most commonly used safe systemic non-biological medications include methotrexate which has been used as early as the 1960s, mycophenolate mofetil which has been used as early as the 1970s, and acitretin which has been used as early as the 1980s. Safe systemic biological medications include infliximab which has been used as early as 2001. Patients and methods: The case of a 51-year-old diabetic and hypertensive male who had moderately severe psoriasis with history of arthritic symptoms is described. Results: The patient had been treated with several topical medications for years; however, the steroid containing topical therapies have been recently linked with worsening of hyperglycemia. Therefore, topical treatment was replaced with oral methotrexate 5 mg twice weekly. After few weeks of methotrexate treatment, there was slight improvement, and therefore increasing the dose of methotrexate to 7.5 mg twice weekly was suggested by the earlier treating physician, however, the patient was reluctant to increase the dose methotrexate because he has already aware of the possible hepatotoxic effect. When the patient presented to us, he had significant area of his body affected and systemic treatment was considered necessary. The decision was made to add oral mycophenolate with attempt of gradually withdrawing methotrexate. According to the published experiences with the use of mycophenolate monotherapy in psoriasis, a satisfactory response is expected to occur in about 70% or less, and therefore the decision was made add topical calcipotriol 0.005% and give once daily at night. Conclusion: The current evidence-based expert opinion suggests that the choice of the treatment of methotrexate resistant psoriasis depends to a large extent on the availability of the medication, and the experience of the treating physician with the available medications. Mycophenolate can be used safely with beneficial effect in severe psoriasis and methotrexate psoriasis.