Clinical Improvement of Erythrodermic Psoriasis Patient Treated with Methotrexate: A Case Report

Cagar Irwin Taufan Pamungkas; Asri Ayu Firdausi; Agnellia Maulidya Utami; Elfindri Okgandita Veranie; Anselma Dyah Kartika Hadi

doi:10.19184/ams.v9i2.38317

Cagar Irwin Taufan Pamungkas dr. Soebandi Regional Hospital Jember, Jember, Indonesia
Asri Ayu Firdausi Citra Husada Hospital, Jember, Indonesia
Agnellia Maulidya Utami Bina Sehat Hospital, Jember, Indonesia
Elfindri Okgandita Veranie Faculty of Medicine, University of Jember, Jember, Indonesia
Anselma Dyah Kartika Hadi Departement of Dermatology and Venereology, dr. Soebandi Regional Hospital Jember, Jember, Indonesia

DOI: https://doi.org/10.19184/ams.v9i2.38317

Abstract

Erythrodermic psoriasis (EP) is a rare form of psoriasis but has a high mortality and morbidity rate. The management of erythrodermic psoriasis includes prevention of complications and administration of immunosuppressant drugs such as methotrexate. This article reports the case of a 37-year-old man with complaints of red, scaly spots almost all over his body since the past month. Initially, the red spots only appeared on the right and left arms and legs. On dermatological examination found lesions on >90% of the patient's total body area in the form of erythematous patches, well-defined, irregular shape and covered with thick scales, there was onycholysis of the toenails, and the Karvslek phenomenon in the patient. Based on the history and physical examination, the patient was diagnosed with erythrodermic psoriasis with a PASI score of 60.2. The patient received oral methotrexate therapy 7.5 mg/week, folic acid once daily, cetirizine 10 mg twice daily, and topical therapy with desoximetasone cream 0.25%. Methotrexate is taken alternately with a single dose of 2.5 mg. Evaluation of patients at 1 month after therapy showed improvement in clinical symptoms with reduced subjective symptoms followed by a change in the PASI score to 45.8. Proper diagnosis and management as well as monitoring for side effects of medication can reduce morbidity and prevent complications from EP.

Keywords: Erythrodermic psoriasis, treatment, methothrexate.

References

Alajlan, A., Madani, A., Qadoumi, T. A., Aljaloud, A., & Alessa, M. (2022). Erythrodermic Psoriasis Managed with Risankizumab. Case Reports in Dermatology, 14(2), 219–224. https://doi.org/10.1159/000525774

Coates, L. C., Merola, J. F., Grieb, S. M., Mease, P. J., & Callis Duffin, K. (2020). Methotrexate in Psoriasis and Psoriatic Arthritis. The Journal of Rheumatology, 96, 31–35. https://doi.org/10.3899/jrheum.200124

da Silva, C. A., Von Kossel, K., Leszczynski, M., Melnik, T., & Riera, R. (2019). Methotrexate for psoriasis. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD010498.pub2

Di Lernia, V., Bonamonte, D., Lasagni, C., Belloni Fortina, A., Cambiaghi, S., Corazza, M., Di
Nuzzo, S., Gisondi, P., Panzone, M., Guarneri, C., & Neri, I. (2016). Effectiveness and Safety of Acitretin in Children with Plaque Psoriasis: A Multicenter Retrospective Analysis. Pediatric Dermatology, 33(5), 530–535. https://doi.org/10.1111/pde.12940

Gudjonsson, J. E., & Elder, J. T. (2019). Psoariasis. In Fitzpatrick’s Dermatology in General Medicine (9th ed., Vol. 1, pp. 197–230).

Khaled, A., Hamida, M. Ben, Zeglaoui, F., Kharfi, M., Ezzine, N., & Fazaa, B. (2012). Traitement du psoriasis par méthotrexate à l’ère des biothérapies : étude chez 21 patients tunisiens. Therapies, 67(1), 49–52. https://doi.org/10.2515/therapie/2012004

Kim, W. B., Jerome, D., & Yeung, J. (2017). Diagnosis and management of psoriasis. Canadian Family Physician, 63(4), 278. http://www.cfp.ca/content/63/4/278.abstract

Liao, W., Singh, R., Lee, K., ucmak, derya, Brodsky, M., Atanelov, Z., Farahnik, B., Abrouk, M., Nakamura, M., & Hao Zhu, T. (2016). Erythrodermic psoriasis: pathophysiology and current treatment perspectives. Psoriasis: Targets and Therapy, Volume 6, 93–104. https://doi.org/10.2147/PTT.S101232

Lin, V. W., Ringold, S., & Devine, E. B. (2012). Comparison of Ustekinumab With Other Biological Agents for the Treatment of Moderate to Severe Plaque Psoriasis. Archives of Dermatology, 148(12), 1403. https://doi.org/10.1001/2013.jamadermatol.238

Lindqvist, T., Salah, L., Gillstedt, M., Wennberg, A., & Osmancevic, A. (2018). Methotrexate Management in Psoriasis: Are We Following the Guidelines? Acta Dermato Venereologica, 98(4), 449–451. https://doi.org/10.2340/00015555-2857

Lo, Y., & Tsai, T.-F. (2021). Updates on the Treatment of Erythrodermic Psoriasis. Psoriasis: Targets and Therapy, Volume 11, 59–73. https://doi.org/10.2147/PTT.S288345

Mahmood, T., Zaghi, D., & Menter, A. (2015). Emerging oral drugs for psoriasis. Expert Opinion on Emerging Drugs, 20(2), 209–220. https://doi.org/10.1517/14728214.2015.1010509

Perhimpunan Dokter Spesialis Kulit dan Kelamin Indonesia (PERDOSKI). (2021). PANDUAN PRAKTIK KLINIS BAGI DOKTER SPESIALIS DERMATOLOGI DAN VENEREOLOGI INDONESIA.
Safitri, P. R., Prawitasari, S., & Rofiq, A. (2020). PSORIASIS ERITRODERMA PADA PASIEN DENGAN SINDROM CUSHING IATROGENIK. MDVI, 47(2), 77–82.

Segar, D., Praharsini, I., & Indira, I. E. (2019). Prevalence and clinical manifestations of patients with psoriasis in RSUP Sanglah from 2017 to 2018. Intisari Sains Medis, 10(3). https://doi.org/10.15562/ism.v10i3.497

Shao, S., Wang, G., Maverakis, E., & Gudjonsson, J. E. (2020). Targeted Treatment for Erythrodermic Psoriasis: Rationale and Recent Advances. Drugs, 80(6), 525–534. https://doi.org/10.1007/s40265-020-01283-2

Stinco, G., & Errichetti, E. (2015). Erythrodermic Psoriasis: Current and Future Role of Biologicals. BioDrugs, 29(2), 91–101. https://doi.org/10.1007/s40259-015-0119-4

World Health Organization. (2016). Global report on PSORIASIS.

Yan, K., Xu, W., Huang, Y., Zhang, Z., Huang, Q., Xin, K. Z., Ma, Y., & Han, L. (2018). Methotrexate restores the function of peripheral blood regulatory T cells in psoriasis vulgaris via the CD73/AMPK/mTOR pathway. British Journal of Dermatology, 179(4), 896–905. https://doi.org/10.1111/bjd.16560