Cutaneous ulceration caused by methotrexate

Kazlow, Dana W; Federgrun, David; Kurtin, Stephen B.; Lebwohl, Mark

doi:10.1067/mjd.2003.388

Cited by 55 publications

(41 citation statements)

References 6 publications

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“…Severe keratinocyte dystrophy was consistently found in the biopsy specimens. The diagnosis of methotrexate toxicity was supported by the similar clinical features to those reported previously [4][5][6][7][9][10][11][12][13][14] and by the blood cell count abnormalities indicating myelotoxicity. Furthermore, no other cause to the mucocutaneous abnormalities was found.…”

Section: Discussionmentioning

confidence: 75%

“…4,19 Methotrexate-induced skin toxicity can occur in the absence of any of the known risk factors, 9 as illustrated by our patient 4, suggesting a role for folate-dependent enzyme polymorphisms. Methotrexate is a highly selective competitive inhibitor of the enzyme dihydrofolate reductase and consequently, decreases the production of thymidylate and DNA.…”

Section: Discussionmentioning

confidence: 87%

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Low-dose methotrexate-induced skin toxicity: Keratinocyte dystrophy as a histologic marker

Delyon

Ortonne

Benayoun

et al. 2015

Journal of the American Academy of Dermatology

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Section: Discussionmentioning

confidence: 75%

Section: Discussionmentioning

confidence: 87%

Low-dose methotrexate-induced skin toxicity: Keratinocyte dystrophy as a histologic marker

Delyon

Ortonne

Benayoun

et al. 2015

Journal of the American Academy of Dermatology

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“…Although ulcerations in methotrexate toxicity are typically superimposed on psoriatic plaques, they may occur on normal skin. [11][12][13][14] Therefore, in cases associated with numerous eosinophils, as in the current case, the histopathologic differential diagnosis may also include a hypersensitivity reaction, such as lichenoid or fixed drug eruption. These conditions were ultimately excluded based on the histopathologic findings of medication toxicity superimposed on psoriatic plaques combined with clinical correlation.…”

Section: Discussionmentioning

confidence: 90%

Acute Mucocutaneous Methotrexate Toxicity Associated With Interface Dermatitis and Numerous Eosinophils

Ferguson¹,

Asarch²,

VanBeek³

et al. 2013

The American Journal of Dermatopathology

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Acute mucocutaneous methotrexate toxicity is not classically associated with prominent tissue eosinophilia. We present a case of acute methotrexate toxicity associated with pancytopenia and mucocutaneous erosion with interface dermatitis and numerous eosinophils. A 79-year-old male, with a history of psoriasis vulgaris on methotrexate therapy, presented with blisters of the oral mucosa, groin, sacrum, and extremities after daily consumption of methotrexate. Examination revealed blisters and erosions localized to psoriatic plaques, the perineum, and the oral mucosa. Laboratory evaluation demonstrated pancytopenia, megaloblastic anemia, and elevated liver function tests. A skin biopsy of an eroded plaque revealed psoriasiform epidermal hyperplasia with epidermal erosion, parakeratosis, and loss of the granular cell layer. There was an underlying band-like lymphoid infiltrate with interface dermatitis, dyskeratotic keratinocytes, and numerous eosinophils. Direct immunofluorescence studies were negative for the deposition of immunoreactants. Methotrexate was held, and the patient received leucovorin resulting in improvement of blood counts and cutaneous lesions. The histopathologic changes associated with acute mucocutaneous toxicity have been described as pauci-inflammatory erosions associated with dyskeratotic keratinocytes to interface dermatitis with necrotic keratinocytes and occasionally associated eosinophils. Although these changes are most often superimposed on psoriatic plaques, they have been reported to occur on normal skin. Therefore, the differential diagnosis may include lichen planus, a lichenoid drug eruption, or a fixed drug eruption, and given the presence of mucosal ulceration, incipient pemphigus vulgaris or paraneoplastic pemphigus vulgaris. This case illustrates that acute mucocutaneous methotrexate toxicity may be associated with both interface dermatitis and numerous eosinophils.

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“…However, there have been case reports of cutaneous ulceration occurring at sites other than the psoriatic plaques. 4,5 In the literature from 1976-96, Pearce and Wilson found 17 patients with cutaneous erosions secondary to MTX toxicity. 6 The most common risk factors for toxicity were an alteration in the dosage or MTX being re-started after a hiatus, renal insufficiency, concomitant use of non-steroidal anti-inflammatory drugs (NSAID), older age, infection, and pustular flare of psoriasis.…”

Section: Discussionmentioning

confidence: 99%