Comparison of efficacy and safety of two dosing of oral methotrexate in patients with moderate to severe plaque psoriasis

Background: Methotrexate has been widely used as an effective systemic therapy for psoriasis. Retrospective data showed efficacy rate of 70-80% but recent RCTs using PASI 75 as primary endpoint showed wide variations in efficacy. Different dosing regimens for methotrexate may explain this variation. Objectives: To compare the efficacy and tolerability of two different dosing regimes of oral methotrexate in patients with moderate to severe plaque psoriasis. Methods: A prospective comparative study was conducted from October 2009 to June 2010. Patients with moderate-to-severe plaque psoriasis were randomized to receive either a ‘step-up dose’ regime (starting dose 7.5mg) or a ‘step-down dose’ regime (starting dose 20mg) of oral methotrexate for 16 weeks. The primary efficacy endpoint was PASI 75. Tolerability and safety were assessed. Results: Forty patients received oral methotrexate with equal numbers in each arm. After 16-week, 55% (11) of patients in ‘step-up dose’ group and 65% (13) of patients in ‘step-down dose’ group achieved PASI 75 (p > 0.05). Significantly higher number of patients in ‘step-down dose’ group achieved PASI 75 at week 4 and week 8 (p < 0.05) compared to ‘step-up dose’ group. One patients from ‘step-down dose’ group discontinued study prematurely due to adverse effect but no significant difference in rate of adverse events was noted. Conclusion: There was no significant difference in efficacy between both regimes at the end of 16 weeks but significant efficacy was observed in patients on ‘step-down dose’ regime as early as week 4. The side effect profile and tolerability were similar.

Local experience on the use of Methotrexate in the treatment of Psoriasis in Hospital Sultanah Aminah, Johor Bahru

Introduction The efficacy of methotrexate in the treatment of psoriasis is well established. However, high-quality data concerning its efficacy and side effects are sparse. The initial administration dose differs among various centres. In Hospital Sultanah Aminah, Johor Bahru, methotrexate is initiated at a starting dose of 0.3mg/kg body weight weekly and is continued until significant clinical response before being tapered to the lowest maintenance dose. The aim of this study is to determine the profile of our local psoriasis patients treated with methotrexate, their response to treatment, their tolerability and the side-effects experienced. Methods This is a retrospective study of all patients who were on methotrexate from January 2005 to December 2008 at the Department of Dermatology, Hospital Sultanah Aminah, Johor Bahru. Results Out of a total of 128 patients, 111 were started on an initial dose of methotrexate of between 15mg/week to 25mg/week. The mean age was 43 years old. 56.8% (63) were males and 43.2% (48) females. The mean body weight was 66 kg, ranging from 39 kg to 103 kg. Methotrexate was indicated for moderate to severe psoriasis in 77.5% (86), psoriatic arthropathy in 7.2% (8) and 15.3% (17) for both indications. Methotrexate was started as a first line in 57.7% (64) of patients, whereas, 19.8% (22) had received phototherapy, 14.4% (16) acitretin and 7.2% (8) cyclosporine in the past prior to being given methotrexate. Good response was noted in 79.3%, (88) of patients, 17.7% (19) moderate and 2.7% (3) had a poor response. Side-effects were noted in 19.8% (22) of patients within the first 6 months, 12.6% (14) due to raised liver enzymes, 3.6% (4) to bone marrow suppression, 2.7% (3) to gastro-intestinal symptoms and 0.9% (1) to central nervous system symptoms. Methotrexate was stopped due to adverse events in 15.3% (17) of patients. Conclusion Methotrexate is effective in the treatment of psoriasis but is limited by side effects, especially raised liver enzymes. However, most of the side effects are mild and reversible on stopping the drug.

Cutaneous Sarcoidosis Mimicing Tuberculoid Leprosy

Sarcoidosis is a chronic systemic disorder of unknown etiology, characterized histopathatologically by non-caseating, epithelioid granulomatous infiltration in various organs.1,2 Cutaneous sarcoidosis is also known as a dermatologic masquerader because the lesions can exhibit many different morphologies.3 We report a patient who was initially diagnosed as having tuberculoid leprosy based on histological findings. He was treated with multi-drug therapy for 18 months without clinical improvement. In addition, he had left panuveitis and mediastinal lymphadenopathy.

Aplasia cutis congenita secondary to maternal exposureto carbimazole during pregnancy. A case report

Aplasia cutis congenita (ACC) is a rare anomaly presenting with absence of skin. It was first reported by Cordon in 1767. About 70% of cases manifests as a solitary defect on the scalp, but sometimes it may occur as multiple lesions. The lesions are typically well demarcated, non-inflamed, and they range in size from 0.5cm to 10cm. ACC may be circular, oval, linear, or stellate in configuration. At birth, lesions may appear as scars or ulcers1. They may appear as parchment-like scars with alopecia. Most lesions occur on the scalp vertex just lateral to the midline, but defects may also occur on the face, the trunk, or the limbs, sometimes symmetrically. The depth may involve only the epidermis and the upper dermis, resulting in minimal alopecic scarring, or the defect may extend to the deep dermis, the subcutaneous tissue, or rarely the periosteum, the skull, and the dura. ACC is most often a benign isolated defect, but it can be associated with other physical anomalies or malformation syndromes. Frieden classified them into 9 groups based on the number and presence or absence of other anomalies1. Nearly 86 percent belong to the first group with a solitary lesion. We report a case of Aplasia Cutis Congenita secondary to maternal exposure to carbimazole during pregnancy.

An unusual case of naevus of Ota and Ito associated with port wine stain

Naevus of Ota is a dermal melanocytic pigmentary disorder that affects predominantly females. It occurs most frequently in Asian populations. Its association with naevus of Ito and a port wine stain is very rare. We report a rare occurrence of these three conditions in a male patient.

Uveitis: A presenting sign of both secondary syphilis and HIV Infection

Uveitis is a well-documented presentation of syphilis with or without concomitant HIV infection1,2. Syphilitic uveitis occurs most frequently during secondary and tertiary phases of the infection and its prevalence has declined in tandem with the decline in syphilis prevalence during the early phase of the HIV epidemic. However, during the past 5 years, there has been a resurgence of syphilis and an increased number of patients with ocular syphilis has been reported3,4. Early diagnosis of ocular syphilis which is highly amenable to simple antibiotic treatment can prevent blindness. Unfortunately, the ocular manifestations of syphilis are indistinguishable from that of other causes. Hence, a high index of suspicion is necessary to diagnose syphilitic uveitis. Awareness and recognition of concurrent syphilitic skin involvement, often mistaken for psoriasis, can aid in the diagnosis. We describe a patient whose ocular syphilis was diagnosed and treated promptly because of the presence of a palmoplantar rash.

Cutis Marmorata Telangiectatica Congenita in a 3-month-old infant

Cutis marmorata telangiectatica congenita (CMCT) is an uncommonly reported, sporadic, congenital cutaneous disorder with persistent cutis marmorata, telangiectasia, and phlebectasia. It may be associated with a variety of other congenital anomalies, including but not limited to undergrowth or overgrowth of an involved extremity. We report a case of a baby with CMCT.

Management of leprosy in the Department of Dermatology, Hospital Sultanah Aminah, Johor Bharu

Background Malaysia has achieved control of leprosy with an incidence rate of 1.1 case per 100,000 population, and a prevalence rate of 0.5 per 10,000 population since 19941. However, recently the incidence has increased with the influx of foreign workers, especially from Indonesia, Nepal and Bangladesh. In order to eliminate leprosy, certain issues of need to be addressed namely, imported cases, default from treatment and drug-resistant cases. Objectives 1. To determine the demography of leprosy patients who attended the Skin Department at Hospital Sultanah Aminah Johor Bahru (HSAJB) for treatment. 2. To determine the clinical subtypes of Hansen’s Disease, the incidence of erythema nodosum leprosum (ENL) and reversal reactions. 3. To review the management, side effects of treatment, and disease surveillance Materials and Methods A 15- year retrospective study of all new cases of Hansen’s disease attending the Skin Clinic from 1992 to 2006 was undertaken. Results A total of 166 patients were treated in the study period, of whom 74.4% were male. The median age at presentation was 37 years (range 4 to 85 years). 33% of the patients were immigrants, 34% local Malays, 27% local Chinese and 6% local Indians. Of the 166 patients, 59% had lepromatous leprosy (LL), 22% tuberculoid leprosy (TT), 9% borderline tuberculoid leprosy (BT), 8% borderline lepromatous leprosy (BL), 1% indeterminate leprosy and 1% neural leprosy. The mean bacteriological index (BI) was 1.63 ± 1.63 std deviations, and the mean morphological index (MI) was 0.77 ± 1.24 std deviations at the time of diagnosis. All patients achieved an MI of zero after three weeks of intensive therapy. 84.6 % of the patients received multiple drug therapy (MBCOMBI) in the blister pack distributed by WHO. The remainder was put on modified regimens, because of side effects or drug resistance. 43% of patients developed reactions. Of these, 21.1% had type I reaction and 22.9% had erythematous nodosum leprosum (ENL). 2 patients developed Lucio’s phenomenon at initial presentation. 53% of these developed reaction at presentation while 47% had reaction after a few months’ treatment. 9.6% of the patients developed side effects secondary to multidrug therapy which necessitated withdrawal of the drugs. The defaulter rate was 15 %. Limitations Retrospective analysis with inadequate documentation is a limitation of this study. In addition, the population studied was limited to referrals being made to the Skin Clinic, which is a tertiary referral center. Conclusions Control and elimination of leprosy still posed a problem as the majority of the foreign patients had lepromatous leprosy, and a high defaulter rate. Although leprosy in Malaysia has reached the elimination target set by the WHO, new cases will continue to be observed in small numbers due to the long incubation period of this disease.