ORIGINAL ARTICLE Low-dose methotrexate treatment for moderate-to-severe atopic dermatitis in adults A Lyakhovitsky,* A Barzilai, R Heyman, S Baum, B Amichai, M Solomon, D Shpiro, H Trau Sheba Medical Center – Dermatology Department, Tel-Hashomer, Ramat-Gan, Israel. *Correspondence: A Lyakhovitsky. E-mail: annaly@bezeqint.net Abstract Background Atopic dermatitis (AD) is a common inflammatory skin disease. Methotrexate (MTX) was suggested as an effective treatment option in cases of moderate-to-severe atopic dermatitis. This study assessed the efficacy and safety of treatment with low weekly doses of methotrexate for moderate-to-severe AD in adults. Methods Twenty adult patients with moderate-to-severe AD were included in this retrospective study. Those patients were unresponsive to topical treatments, antihistamines and at least one of the second-line treatments. MTX in low weekly doses of 10–25 mg was administered orally or intramuscularly with folic acid supplementation 5 mg per week for at least 8–12 weeks. The response to treatment was evaluated by change in SCORAD (SCORing Atopic Dermatitis), DLQI (Dermatology Quality of Life Index) and the global assessment of the clinical response score. Results After 8–12 weeks of treatment, we observed an objective response in most patients. There were 16 responders and 4 non-responders. The mean SCORAD and DLQI decreased by 28.65 units (44.3%) and 10.15 units (43.5%), respectively. The first improvement was observed after a period ranging from 2 weeks to 3 months (mean 9.95 w ± 3.17). Treatment was more effective in adult onset AD than in childhood onset. Tolerance of treatment was good. However, nausea and an increase of liver enzymes were observed in 5 patients and 3 of them required a transient discontinuation of MTX. One patient developed peripheral neuropathy, which was resolved several weeks after the discontinuation of MTX. Conclusion MTX seems to be an effective and safe second-line treatment for patients with moderate-to-severe atopic dermatitis. A randomized, controlled study is warranted. Received: 12 February 2009; Accepted: 18 May 2009 Keywords atopic dermatitis (AD), corticosteroids (CS), DLQI (Dermatology Quality of Life Index), methotrexate (MTX), SCORAD (SCORing Atopic Dermatitis) index Conflicts of interest None declared. Introduction Atopic dermatitis (AD) is a common inflammatory skin disease affectingbetween10%and20%ofchildrenand1%and3%ofadults. 1,2 It is characterized by dry skin, intense itching, inflammation and exudation. AD causes significant physical, psychological and social distress. The prevalence of AD has increased steadily over the last 30 years. 1,2 The disease accounts for 10% to 20% of all referrals to dermatologists and about 30% of dermatologic consultations in general practice. 3 At present, there is no 100% life-long cure for AD. Management comprises avoidance of trigger factors (irritants, microbes, psychological stress and allergens), skin moisturizers, antihistamines and anti-inflammatory agents. Topical steroids and calcineurin inhibitors are the current standards for topical anti-inflammatory therapy. However, there are considerable safety concerns associated with long-term use of topical steroids. 4 The treatment with topical immunomodulators is also limited by the body surface involved. 4 Patients with moderate-to-severe disease refractory to a combination of topical agents and antihistamines may require second-line treatment such as phototherapy or systemic immunosuppressants. The side-effects profile of systemic steroids over long periods or at high doses is well known. Therefore, there is a need for safe effective therapy for control and maintenance of the disease. This is why over the last 50 years, many steroid-sparing drugs have been assessed, and yet no ideal candidate has been found. MTX has been documented to be effective in adult AD, 5–8 palmoplantar pompholyx 9 and eczema in the elderly. 10 Although ª 2009 The Authors JEADV 2010, 24, 43–49 Journal compilation ª 2009 European Academy of Dermatology and Venereology DOI: 10.1111/j.1468-3083.2009.03351.x JEADV