The Use of Methotrexate, Alone or in Combination With Other Therapies, for the Treatment of Palmoplantar Psoriasis
August 2015 | Volume 14 | Issue 8 | Original Article | 888 | Copyright © 2015
Jenna M. Wald MD,a Daniel M. Klufas BS,a and Bruce E. Strober MD PhDa,b
aDepartment of Dermatology, University of Connecticut Health Center, Farmington, CT
bProbity Medical Research, Waterloo, Ontario, Canada
Palmoplantar psoriasis is a chronic debilitating type of psoriasis. Treatment options for this disease are poorly studied. This chart review evaluated the use of methotrexate alone and in combination with 7 other systemic therapies in 48 patients with palmoplantar psoriasis. The findings demonstrate that methotrexate is a relatively well-tolerated and effective treatment for palmoplantar psoriasis, amenable as either monotherapy or in combination with other systemic agents.
J Drugs Dermatol. 2015;14(8):888-892.
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Psoriasis is a chronic immune-mediated inflammatory skin disease that afflicts approximately 2-4% of the world population.1 Palmoplantar psoriasis (PP) affects approximately 5% of all psoriasis patients and may be particularly resistant to treatment.2 PP is characterized by well-demarcated, erythematous, scaly plaques of the palms and/or soles, with or without concomitant involvement skin; additional findings include pustules, known as palmoplantar pustular psoriasis (PPP), nail involvement, and painful fissures.2 Unlike chronic plaque psoriasis (CPP), PP has a significant discordance between Body Surface Area involvement (BSA) and quality-of-life impact.1,3
Current PP treatment involves therapies developed for CPP, such as topical therapies, ultraviolet phototherapy, oral retinoids, and newer small molecule and biologic immunomodulators. Few formal studies have been performed on palmoplantar psoriasis, as patients with low BSA of involvement necessarily are excluded from the clinical trials evaluating the newer medications. 1,3 Consequently, data on treatments for PP are limited to case reports and small studies, leaving providers without firm evidence-based guidelines regarding effective therapy. Methotrexate has been shown effective in the treatment of PP.2,4,5 This case series reviews the use of methotrexate, alone or in combination with other therapies, as treatment for PP patients treated at single center. Emphasis is on patient outcomes and treatment tolerability.
After obtaining IRB approval, the medical record numbers were obtained for patients ≥18 years-old seen at a solitary referral-based university setting. Seventy patients were consecutively identified. All patients’ charts were reviewed for diagnosis of PP, treatment with methotrexate, and adequate follow-up visits allowing for an assessment of efficacy, tolerability, and safety.
Patient demographic data were collected from patient intake questionnaires and physician records (Table 1). Treatment groups included methotrexate as a monotherapy and in combination with another systemic therapy. If a medication was added, stopped, or switched the patient was considered a part of a new treatment group and treatment duration was started over. Data within a given treatment group were excluded if no follow-up had occurred since initiating therapy, if the patient was on prednisone for any reason, or if treatment duration was unavailable (ie, patient self-discontinued medication at an unknown time). Failure to respond to high potency topical corticosteroids and other topical medications was a prerequisite for the receipt of a systemic agent, and therefore topical therapies were not delineated in the treatment groups. Rather, it was noted how many patients in a given treatment group used adjuvant topical therapy. Patient years, or the combined treatment duration of all patients in a single treatment group, were calculated for each treatment group. Adverse events (AEs) were defined as any new medical condition or worsening of an existing condition, regardless of association with treatment.
Patients’ disease was scored using the Physicians Global Assessment (PGA). The PGA is a tool regularly used during patient visits at our site to assess a clinician’s impression of disease severity at a single point in time on a 5 point scale (0-4) based on degree of erythema, induration, and scale; 0 indicating no active disease, or clear, and 4 indicating worst severity. PGA data were analyzed at 0-12, 12-24, 24-36, and 36-52 weeks