Low-dose oral pulse methotrexate as monotherapy in elderly patients with bullous pemphigoid

Background: Prednisone alone or in combination with an immunosuppressive dr ug is usually effective in controlling bullous pemphigoid. However, cortico steroids often cause potentially hazardous side effects, especially in elde rly patients. Objective: Our purpose was to evaluate low-dose treatment with methotrexate in elderly patients with generalized bullous pemphigoid. Methods: Oral methotrexate, at an initial dosage of 5 mg/wk, was given to 1 1 consecutive patients older than 70 years of age who were not responding t o potent topical steroids. If the response was insufficient, the methotrexa te dose was increased by 2.5 mg/wk to a maximum of 12.5 mg/wk. Results: All patients responded with a marked and rapid decrease in disease activity. The disease was controlled in the majority of patients (8 of 11) with 5 to 7.5 mg of methotrexate per week. Three patients required a weekl y dose of 10 to 12.5 mg. At 24 months of follow-up 7 patients were in compl ete remission and did not require methotrexate. Conclusion: Our study suggests that low-dose oral pulse methotrexate consti tutes an effective therapeutic alternative in elderly patients with general ized bullous pemphigoid.