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Cutaneous erosions: a herald for impending pancytopenia in methotrexate toxicity

Mallory B Shiver1, Lauren A Hall, Kelly B Conner

  • 1The University of Arkansas for Medical Sciences.

Dermatology Online Journal
|July 22, 2014
PubMed

Insights

Methotrexate (MTX) can cause rare skin erosions, sometimes leading to fatal pancytopenia, even in patients without psoriasis. Early recognition and MTX discontinuation are crucial for preventing severe outcomes.

Area of Science:

  • Dermatology
  • Hematology
  • Toxicology

Background:

  • Low-dose methotrexate (LDMTX) is used for psoriasis treatment.
  • MTX toxicity can manifest as psoriatic plaque erosions, a rare side effect.
  • These erosions may herald impending pancytopenia.

Observation:

  • This report details three rare cases of MTX-induced cutaneous erosions.
  • Two cases involved fatal MTX-induced psoriatic plaque erosions.
  • One case presented with MTX-induced erosions in clinically normal skin without a psoriasis history.

Findings:

  • All patients were elderly, on proton pump inhibitors, and had a history of NSAID use.
  • Erosions appeared acutely after a change in MTX dosage.
  • Pancytopenia followed the onset of skin erosions in all reported cases.

Implications:

  • Physicians must be aware of MTX-induced cutaneous erosions as a potential sign of bone marrow suppression.
  • Prompt discontinuation of MTX and initiation of treatment are vital.
  • Increased physician awareness can prevent fatal outcomes associated with MTX toxicity.

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