Pharmacology and therapeutics Methotrexate for treatment of atopic dermatitis in children and adolescents Maneka Deo, MBChB, Anthony Yung, MBChB, FRACP, CCST, Sarah Hill, MBChB, FRACP, and Marius Rademaker, FRCP, FRACP, DM Department of Dermatology, Waikato Hospital, Hamilton, New Zealand Correspondence Maneka Deo Department of Dermatology Waikato Hospital Hamilton New Zealand E-mail: manekad@adhb.govt.nz doi: 10.1111/ijd.12314 Abstract Background Low-dose methotrexate is becoming established as a second-line treatment for atopic eczema in the adult population, but there has been a paucity of data to support its use for this indication in the pediatric population. Methods A retrospective review was undertaken of patients aged 18 years and under started on methotrexate between January 2005 and April 2010, at a hospital-based dermatology department in New Zealand. Results Thirty-one patients (17 females, mean age 10 years, range 3–18 years) were reviewed. Methotrexate was found to be effective or very effective in 75% and ineffective in 25%. The mean duration of treatment for those who responded to methotrexate was 14 months (range 2–38 months), 74% of patients were still on treatment at the time of last review. The most common adverse effect was minor nausea in four patients (14%) and non-significant elevation of liver enzymes (four patients). No serious adverse effects were noted. Conclusion In our experience, methotrexate has a good safety/tolerability profile when used in low dose for the treatment of atopic dermatitis in children and adolescents and appears to be effective. Formal comparative studies are needed. Introduction Atopic dermatitis is a common inflammatory skin disease in the pediatric and adult population. It is a major cause of morbidity, with effects on growth and development, sleep quality, school attendance, and psychosocial well- being of the affected individual as well as their family. 1 The reported prevalence of the condition ranges from 0.2 to 24.6% in the pediatric age group with significant geo- graphic variation. 2 There is a relatively high prevalence of atopic dermatitis in New Zealand, with reported figures of 15% in those aged 6–7 years and 8.8% in those aged 13–14 years. 2 The mainstay of treatment for atopic dermatitis in childhood remains topical corticosteroids, with topical calcineurin inhibitors and phototherapy 3 being commonly used alternatives. Systemic treatments are often required in severe eczema, which does not respond adequately to other treatments. 4 Traditionally used systemic therapies include cyclosporine and azathioprine; however, side effects can be problematic with these medications, and the necessary blood monitoring can affect adherence, par- ticularly in children and adolescents. Low-dose metho- trexate is now fairly well established as a second-line treatment for atopic eczema in the adult population, 5–8 although double-blind placebo-controlled studies are lack- ing. While methotrexate has well-established safety and efficacy data for use in juvenile rheumatoid arthritis and pediatric Crohn’s disease, 9–11 there has been a paucity of data to support its use for atopic eczema in children. Recently, a case series of pediatric patients with discoid eczema reported its efficacy and safety. 12 We review our retrospective experience of methotrexate in children and adolescents with atopic dermatitis. Materials and methods The clinical records of patients aged 18 years or below who were started on methotrexate between January 2005 and April 2010 at the dermatology department of Waikato Hospital, Hamilton, New Zealand, were reviewed. Demographic details as well as clinical details of the patient’s dermatological disease, previous treatments, and response to methotrexate were analyzed. Data have been recorded prospectively for the purpose of clinical management of individual patients rather than for research/review purposes, so typical clinical trial data ª 2014 The International Society of Dermatology International Journal of Dermatology 2014 1