Recurrent impetigo herpetiformis successfully treated with methotrexate

Abstract

due to MTX is reported in a small numbers of patients with psoriasis. 5-7 Cutaneous ulceration by MTX toxicity is an exclusion diagnosis, and its pathogenic mechanism may be multifactorial, including direct toxicity of the drug in addition to local factors. 8 Lawrence and Dahl 5 described two type of skin ulceration in patients with psoriasis being treated with MTX. In type 1 ulceration, psoriatic lesions became painful and eroded shortly after starting MTX. Type 2 ulcers occurred in skin clinically uninvolved with psoriasis but affected by other pathologies, such as stasis dermatitis, scars and had a variable relationship to the duration of MTX treatment. In both types, the pathogenic mechanism was thought to be direct toxicity of MTX.Kazlow et al. 6 reported a 58-year-old man with psoriasis that had been treated with MTX and had ulcers developed within psoriatic plaques (type 1), in an abdominal scar (type 2) and on the lower lip. Our patient's lesions were evaluated as type 1 erosions.Pearce and Wilson 7 found 17 patients who had experienced cutaneous erosion believed to be secondary to MTX toxicity. The most common risk factors in these patients were the use of non-steroidal anti-inflammatory drugs and an alteration in MTX dosage. They also reported a possible association between the patient's age (55 years or older) and toxicity. Our case was associated with these risk factors, too. Her age was older than 55 and she had been using meloxicam.The erosions and ulcerations developed within psoriatic plaques of the patients receiving MTX for psoriasis must be considered as a rare side effect caused by MTX. Folic acid must be absolutely used with MTX to decrease the side-effects. And also the fact that non-steroidal anti-inflammatory drugs should not be used under MTX therapy since they can increase the risk of erosions and ulcerations. Evidence-based (S3) guidelines for the treatment of psoriasis vulgaris. J Dtsch Dermatol Ges 2007; 5(s3): 1-119. 4 Bangert CA, Costner MI. Methotrexate in dermatology. Dermatol Ther 2007; 20: 216-228. 5 Lawrence CM, Dahl GC. Two patterns of skin ulceration induced by methotrexate in patients with psoriasis. J Am Acad Dermatol 1984; 11: 1059-1065. 6 Kazlow DW, Federgrun D, Kurtin S, Lebwohl MG. Cutaneous ulceration caused by methotrexate. J Am Acad Dermatol 2003; 49(2 Suppl Case Reports): S197-S198. 7 Pearce HP, Wilson BB. Erosion of psoriatic plaques: an early sign of methotrexate toxicity. J Am Acad Dermatol 1996; 35: 835-838. 8 Del Pozo J, Martinez V, Garcia-Silva J et al. Cutaneous ulceration as a sign of methotrexate toxicity. Recurrent impetigo herpetiformis successfully treated with methotrexateEditor A 25-year-old primigravida at 36th week of gestation was observed with multiple erythematous annular plaques with crusts and perypheric pustules, located on the scalp, thoracoabdominal wall, upper and lower limbs (Fig. 1), accompanied with fever with no other systemic symptoms. These lesions appeared during the 30th week of gestation. The personal and familiar medical history w...

Impetigo Herpetiformis with Gestational Hypertension: A Case Report and Literature Review

“…Although its absolute safety is difficult to prove, Puig et al [13] reviewed pregnancy outcomes of 219 cases who had been exposed to tumor necrosis factor antagonists and concluded that women who conceived while taking infliximab or other anti-tumor-necrosis-factor-α agents can be reassured regarding the continuation of pregnancy. Other studies have reported the successful treatment of persistent IH lesions using methotrexate or retinoid photochemotherapy [14,15]. However, the critical days for isotretinoin-induced defects appear to be any time between 15 and 40 days after conception, with most studies indicating that of the pregnancies that reach 20 weeks gestation, 25–30% will show malformation [16].…”

Impetigo Herpetiformis during Pregnancy: A Case Report and Literature Review

“…In some severe cases, it is necessary to increase the dose to 40-60 mg a day to control the symptoms [2,22]. However, some cases reported that the patients were unresponsive to corticosteroid therapy [10,17,22]. In progressive cases, oral cyclosporine is the second-line therapy for IH and antibiotics should be administered to treat or prevent secondary infection [2,9,17,22].…”

“…IH mainly afflicts pregnant women during the third trimester of pregnancy but it may also occur in the first trimester of pregnancy, puerperium or menstrual period, and it may even occur in men [8,11,12,13,14]. In patients who suffered from IH before, the disease recurs at an earlier gestational age during a subsequent pregnancy [7,9,10]. Although genetic background is not considered in our literature review, several familial cases have been reported [15,16].…”

“…According to the literature review, the treatments of IH mainly include systemic corticosteroids (prednisone), cyclosporine, antibiotic, methotrexate, ultraviolet A (PUVA), system retinoids and clofazimine [2,7,8,9,10,11,12,17,18,22,23,24]. At the beginning of IH or in mild cases, corticosteroids are usually efficacious at a low dose of 15-30 mg a day.…”

“…According to the literature, although the causes of impetigo herpetiformis are still unknown [3,4], complications like hypoparathyroidism and hypocalcemia are common in patients [5,6,7,8]. Generally the patients recovers after delivery, but IH frequently recurs in subsequent pregnancy [2,7,8,9,10]. Early diagnosis and treatment is important in order to get a better prognosis for both the mother and fetus.…”