An increasingly important approach to the management of patients with sever
e psoriasis is the concurrent use of two systemic treatments, Previous guid
elines have advised against the use of methotrexate and cyclosporin in comb
ination. We report the successful use of a combination of methotrexate and
cyclosporin in the treatment of 19 patients with severe, recalcitrant psori
asis, 15 of whom had psoriatic arthropathy, Most patients had previously re
ceived two or more systemic treatments. Before combination treatment was st
arted nine of the patients were taking methotrexate and 10 were taking cycl
osporin at the maximum tolerated doses. The duration of combination treatme
nt was bimodally distributed, with seven patients having short-term treatme
nt (mean +/- SD duration 18.9 +/- 15.7 weeks) and 12 patients having long-t
erm treatment (mean +/- SD duration 193.2 +/- 160.6 weeks), Those patients
who received short-term treatment did not develop any evidence of toxicity
from either agent. Of those patients on long-term treatment, three develope
d mild impairment of renal function that returned to normal following a red
uction in dose of cyclosporin, and three had impairment of renal function (
following long-term cyclosporin monotherapy) that improved, but did not nor
malize, following a reduction in dose of cyclosporin, In each case, combina
tion treatment for psoriasis resulted in good control. of both skin and joi
nt problems using lower doses of each agent than would have been used for m
onotherapy, We conclude that the combination of methotrexate and cyclospori
n is an effective treatment for this group of patients.