Methotrexate in atopic eczema. Comments to: Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part II

The wide variety of methotrexate dosing regimens for the treatment of atopic dermatitis: a systematic review

Background:Methotrexate is an off-label therapy for atopic dermatitis. A lack of consensus on dosing regimens poses a risk of underdosing and ineffective treatment or overdosing and increased risk of side effects. This systematic review summarizes the available evidence on dosing regimens.Materials and methods:A literature search was conducted, screening all randomized controlled trials (RCTs) and guidelines published up to 6 July 2023, in the MEDLINE, Embase, and Cochrane Library databases.Results:Five RCTs and 21 guidelines were included. RCTs compared methotrexate with other treatments rather than different methotrexate dosing regimens. The start and maintenance doses in RCTs varied between 7.5-15 mg/week and 14.5-25 mg/week, respectively. Despite varied dosing, all RCTs demonstrated efficacy in improving atopic dermatitis signs and symptoms. Guidelines exhibited substantial heterogeneity but predominantly proposed starting doses of 5-15 mg/week for adults and 10-15 mg/m2/week for children. Maintenance doses suggested were 7.5-25 mg/week for adults and 0.2-0.7 mg/kg/week for children. One guideline suggested a test dose and nearly half advised folic acid supplementation.Conclusion:This systematic review highlights the lack of methotrexate dosing guidelines for atopic dermatitis. It identifies commonly recommended and utilized dosing regimens, serving as a valuable resource for clinicians prescribing methotrexate off-label and providing input for an upcoming consensus study.

International consensus on methotrexate dosing for patients with atopic dermatitis: An eDelphi study

BACKGROUND

Despite the widespread off-label use of methotrexate (MTX) for the treatment of atopic dermatitis (AD), there is limited high-quality evidence on dosing regimens and existing guidelines do not provide clear recommendations regarding dosing strategies.

OBJECTIVE

The aim of this study was to achieve international consensus among AD experts to standardize the dosing regimen for MTX treatment in adults and children with AD.

METHODS

An electronic Delphi (eDelphi) study was conducted from October 2021 to September 2022. Recruitment was conducted through dermatology societies and AD interest groups. Participation was open to dermatologists and dermatology residents experienced in treating AD patients with MTX. The study consisted of three online rounds. The first round was informed by a systematic review of relevant literature, and subsequent rounds were adjusted based on the results of the previous round. Participants voted on 19 proposals using a 9-point scale (1-3 disagree, 4-6 neither agree nor disagree, 7-9 agree). Consensus was achieved when at least 70% of participants agreed, and less than 15% disagreed. Proposals that did not reach consensus in the first three rounds were discussed in a consensus meeting, where consensus was defined as less than 30% disagreement.

RESULTS

In total, 152 participants completed Round 1, 104 (68%) completed all survey rounds, and 43 (28%) joined the consensus meeting. Consensus was achieved on 7 proposals in Round 1, 4 in Round 2 and 6 in Round 3. The final 2 proposals reached consensus during the consensus meeting. Consensus topics include test dose, start dose, maximum dose, administration route, dosing schedule, management of stopping treatment, treatment duration and folic acid supplementation.

CONCLUSIONS

This eDelphi study achieved consensus on 19 proposals related to MTX dosing for adults and children with AD. These results aim to guide prescribing decisions and encourage a standardized global approach to MTX use in AD.

Vulvar Pruritus: A Review of Clinical Associations, Pathophysiology and Therapeutic Management

Vulvar pruritus is an unpleasant sensation and frequent symptom associated with many dermatologic conditions, including infectious, inflammatory and neoplastic dermatoses affecting the female genitalia. It can lead to serious impairment of quality of life, impacting sexual function, relationships, sleep and self-esteem. In this review, common conditions associated with vulvar itch are discussed including atopic and contact dermatitis, lichen sclerosus, psoriasis and infectious vulvovaginitis. We review the potential physiologic, environmental and infectious factors that contribute to the development of vulvar itch and emphasize the importance of addressing their complex interplay when managing this disruptive and challenging symptom.