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Year : 1992  |  Volume : 58  |  Issue : 2  |  Page : 77-79

Relapse in psoriasis after methotrexate

Correspondence Address:
R Dhir

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A preliminary report on follow up of 15 patients treated with Methotrexate (MTX) is presented. All 5 cases where MTX was discontinued after achieving remission and giving maintenance therapy for 8 to 12 weeks have relapsed within 10 weeks of stoppage of MTX. No major toxicity was seen in any patient.

Keywords: Psoriasis, Methotrexate, Relapse

How to cite this article:
Dhir R, Tutakne M A, Chari K. Relapse in psoriasis after methotrexate. Indian J Dermatol Venereol Leprol 1992;58:77-9

How to cite this URL:
Dhir R, Tutakne M A, Chari K. Relapse in psoriasis after methotrexate. Indian J Dermatol Venereol Leprol [serial online] 1992 [cited 2020 Oct 20];58:77-9. Available from:

  Introduction Top

Psoriasis is a chronic papulosquamous disorder of unknown aetiology affecting 1to 3 percent of the general population. [1] Methotrexate (MTX) has a distinct place in the therapeutic armoury of the treating dermatologist. It is being used for the treatment of psoriasis for the last 25 years. [2],[3] Since then, the effectiveness of MTX has been proved in a large number of studies. [4],[5] The Psoriasis Task Force of National Program of Dermatology has specified the indications for use of MTX in the treatment of psoriasis. [6] The side effects and contraindications of MTX have been exhaustively studied and are well known. [7]

From our country there are only few reports of use of MTX in psoriasis. [8] Although the effectiveness of MTX in psoriasis is well documented, chances of relapse and further treatment of such relapses is not well known. In the present study an attempt was made to discontinue treatment after achieving remission and observe for relapse. A preliminary report of the ongoing study is presented as all patients in whom treatment was discontinued have relapsed.

  Materials and Methods Top

Fifteen patients who had more than 50 percent involvement of the total surface area of the skin and who had not responded well to conventional modalities of treatment were selected for this study. A careful history excluded the known contraindications of MTX like pregnancy, hepatitis, peptic ulcer and excessive alcohol intake.

Pretreatment investigations included a complete haematological profile, hepatic and renal function tests, X-ray chest and a test for blood sugar. During treatment the haematological profile was repeated every week for the initial 4 weeks and subsequently every 2 weeks. Liver and renal function tests were repeated every 2 months. Clinical examination was done every week for the first 4 weeks and thereafter every 2 weeks. MTX was started in a weekly dose of 7.5 mg and increased to a maximum of 15.0 mg in 4 weeks. It was given in 3 twelve hourly doses.

Response to treatment was evaluated clinically by documenting the changes in erythema, scaling and clearance of skin lesions. On attaining clinical remission the dose of MTX was reduced and the patients were kept on maintenance dose of 5.0 mg per week for 8-12 _ weeks before discontinuing the treatment.

  Results Top

Out of 15 patients, 10 were males and 5 were females. The age ranged from 35 to 67 years. The duration of psoriasis varied from 1 to 25 years with a mean of 11.6 years. One of the patients had extensive erythroderma and there was history of hepatitis (5 years back) in 1 patient. Ten patients showed varying degrees of nail involvement and 2 patients had joint involvement.

Nausea and/or vomiting were seen in 6 out of 15 patients while 5 out of 15 patients complained of malaise and headache. Nausea and vomiting were seen on the day MTX was administered and persisted for 6 to 12 hours after the last dose. Treatment had to be discontinued in 1 patient because of severe nausea and vomiting. No other toxicity was encountered during the period of observation.

The dosage was not increased beyond 15 mg per week as the response to treatment was satisfactory at this dosage level. The average time required to attain clinical remission was 10 weeks, although it took 40 weeks in 1 case and 28 weeks in another. There was no relationship between duration of psoriasis, age of the patient, presence of nail and/or joint involvement and therapeutic response.

Out of 15 patients, 4 were lost to follow up and in 1 case treatment was discontinued. [Table - 1] gives the details of follow up in remaining 10 cases. It is seen that all the 5 cases in whom the treatment was discontinued had relapsed. The remaining patients have hence been kept on longer maintenance therapy.

  Comments Top

The treatment of psoriasis remains a challenging and often a frustrating experience for dermatologists. The spectre of a relapse looms large over the minds of the patient and the treating dermatologist.

In this context, oral MTX therapy offers distinct advantages. The weekly dose schedule is very convenient and the therapeutic response is quick and assured. Nausea and vomiting occur in many, but patients often prefer once a week nausea or vomiting to the daily messy and often nauseating local applications. Hepatic toxicity remains the main cause for worry, it can be avoided by a careful patient selection and follow up.

To date, there are no guidelines regarding the duration of treatment with MTX; should it be life long or till the patient develops hepatitis? Considering the long term side effects of MTX, is it fair to continue treatment indefinitely? In this study an attempt was made to discontinue treatment on attaining remission. Unfortunately, it led to a relapse in all the patients. It is apparent that patients require to be on maintenance therapy for a longer duration, but for how long is the million dollar question. We now propose to keep our patients on maintenance treatment for a longer duration, but on lower dosage, before discontinuing the treatment.

  References Top

1.Farber EM, Naill. Epidemiology in psoriasis research. Hawaii Med J 1982; 41 : 430.  Back to cited text no. 1    
2.Van Scott EJ, Auerbach R, Weinstein G. Parenteral methotrexate in psoriasis. Arch Dermatol 1964; 89 : 550 - 6.  Back to cited text no. 2    
3.Roenigk HH Jr, Fowler B W, Curtis GH. Methotrexate for psoriasis in weekly oral doses. Arch Dermatol 1969; 99 : 86 - 93.  Back to cited text no. 3    
4.Weinstein GD. Methotrexate. Ann Intern Med 1977; 86: 199.  Back to cited text no. 4  [PUBMED]  
5.Weinstein GD, Frost P. Methotrexate for psoriasis. Arch Dermatol 1971; 103: 33.  Back to cited text no. 5  [PUBMED]  
6.Roenigk H, Maibach H, Weinstein G. Use of Methotrexate in psoriasis. Arch Dermatol 1972; 105: 363-5.  Back to cited text no. 6    
7.Nyfors A. Methotrexate therapy for Psoriasis Effect and side effects with particular reference to hepatic changes : A Survey. Aarhus, Denmark, Laegeforeningens Forlag. 1980;  Back to cited text no. 7    
8.Kaur S, Kaur 1, Bhushnurmath S R, et al. Methotrexate therapy for psoriasis (A preliminary report). Ind J Dermatol Venereol 1986; 52: 155-7.  Back to cited text no. 8    


[Table - 1]


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