Combination treatment with methotrexate and cyclosporin for severe recalcitrant psoriasis

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.