Acta Dermato-Venereologica 98-5CompleteContent | Page 10

501 CLINICAL REPORT Methotrexate Treatment for Pityriasis Rubra Pilaris: A Case Series and Literature Review Lukas KOCH 1 , Clemens SCHÖFFL 1 , Werner ABERER 1 and Cesare MASSONE 2 Department of Dermatology, Medical University of Graz, Austria, and 2 Dermatology Unit, Galliera Hospital, Genova, Italy 1 Treatment recommendations for pityriasis rubra pila- ris (PRP) are based solely on case reports and small case series, as to-date no randomized controlled trials are available. We present here a case series of 3 pa- tients and a literature review of 28 studies treating a total of 116 patients, with the aim of providing data regarding efficacy and safety of methotrexate in the treatment of PRP. Methotrexate was effective in our patients; the review showed an overall response rate of 65.5% with complete clearing in 23.3% and excel- lent improvement in 17.2%, respectively. After exclu- ding studies with other concurrent systemic therapies or low reliability, the overall response rate increased to 90.9%, with complete clearing in 40.9% and excel- lent improvement in 31.8%, respectively. Sixteen ad- verse reactions, of which 11 were mild, were observed in 15 patients (12.9%). In conclusion, the available literature supports good response rates and safety of methotrexate in PRP. Key words: pityriasis rubra pilaris; methotrexate; treatment; response; review. Accepted Jan 15, 2018; Epub ahead of print Jan 16, 2018 Acta Derm Venereol 2018; 98: 501–505. Corr: Cesare Massone, Dermatology Unit–Ospedali Galliera, Via Volta 6, IT-16128, Genova, Italy. E-mail: [email protected] T reatment recommendations for pityriasis rubra pila- ris (PRP) are based solely on case reports or small case series, as to-date no randomized controlled trials assessing different treatment efficacies are available. We report here our experience with methotrexate (MTX) in the treatment of PRP and provide a systematic review of the literature regarding the efficacy and tolerability of treatment with MTX. CASE REPORTS Case 1 A 55-year-old man consulted our outpatient clinic in August 2014 with a 2-month history of skin changes, which had started on the scalp and spread consecutively to his shoulders and trunk. Prior treatment with systemic corticosteroids had not improved the disease. Apart from an umbilical hernia the patient was otherwise healthy and did not take any medication regularly. Skin examination revealed scaling erythematous to orange confluent plaques with islands of unaffected skin on his trunk, buttocks, neck, face and scalp (Fig. 1A, B). Furthermore, the patient had palmoplantar keratoderma with fissures; the affected body surface area (BSA) was approximately 50%. Histopathological examination of a skin biopsy was compatible with a clinical diagnosis of PRP and after unremarkable pre-treatment screening (Table SI 1 ), MTX treatment was initiated, 20 mg subcu- taneously once weekly, followed by 5 mg oral folic acid substitution every following day. At 1-month follow-up there was considerable impro- vement in the erythema on the trunk, but scaling and erythema on the arms and palmar keratoderma persisted. The dosage of MTX was increased to 25 mg once weekly. At 4-month follow-up the patient showed further improvement on the trunk, but only little improvement of palmoplantar keratoderma, which later completely disappeared after 9 months of MTX treatment, when only a few erythematous non-scaling patches persisted on the trunk. MTX was then consecutively reduced each month, down to 7.5 mg/week in February 2016, when the skin had almost completely cleared. MTX was ceased in June 2016: the total MTX dosage applied was 817.5 mg, with no adverse drug reactions during the whole treatment period. A 26-month follow-up in October 2016 revealed an almost complete remission of PRP with minimal non- scaling tender plaques on the ventral trunk affecting less than 1% of the BSA (Fig. 1C, D). Case 2 A 50-year-old man with no comorbidities or long-term medication had developed facial erythema with scaling in June 2015, which then had spread to the trunk and arms after 2 weeks. He was hospitalized in our inpatient clinic in July, with a diffuse-scaling erythema covering approximately 50% of the BSA with multiple islands of sparing. The palms showed orange-red discoloration with mild keratoderma. A skin biopsy was compatible with the diagnosis of PRP and after unremarkable pre- treatment screening MTX was initiated, 10 mg/week subcutaneously, followed by 5 mg oral folic acid every following day. The MTX dose was increased by 2.5 mg/ https://www.medicaljournals.se/acta/content/abstract/10.2340/00015555-2885 1 This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta Journal Compilation © 2018 Acta Dermato-Venereologica. doi: 10.2340/00015555-2885 Acta Derm Venereol 2018; 98: 501–505