Treatment of extensive plaque psoriasis and psoriatic arthropathy using methotrexate in a patient with high serum alkaline phosphatase

Abstract

Background: Psoriasis is an autoimmune inflammatory, chronic, and relapsing disease of the skin, which can also present with severe joint inflammation and deformity. There are many treatment options, but the severe forms of psoriasis are treated successfully with cytotoxic and biologic therapies. Methotrexate being cheap and available in Sudan is considered a good option for patients with severe and extensive forms of psoriasis. One of the main drawbacks is hepatotoxicity. The aim of this report is to share an experience of treating the patient with oral methotrexate in the presence of a relative contraindication to this therapy.

Method: We present a 60-year-old female with extensive skin psoriasis and psoriatic arthropathy. Investigations showed high serum alkaline phosphatase and low serum albumen. Other liver enzymes, CBC, ultrasound abdomen were all unremarkable. Patient was admitted and a weekly dose of methotrexate was given in addition to topical preparation and supportive treatment; three months later, patient improved and was moved to topical therapy. A check of serum alkaline phosphatase and albumen every week was done.

Results: The patient was successfully and safely treated with methotrexate. Serum alkaline phosphatase was normal within the second month treatment, and serum albumen was normal after only one month of treatment.

Conclusion: High serum alkaline phosphatase is considered a relative contraindication to the use of methotrexate, high level can be found in bone diseases. Serum albumen can be low in dermatologic diseases with excessive shedding of scales and can be corrected with protein formulas and high protein diets.

Recommendations: Methotrexate is recommended for the treatment of severe morbid forms of psoriasis. The biologic therapy for severe forms of psoriasis is now available and can be a good alternative for the treatment of severe forms of psoriasis in good centers and for patients who can afford and in patients with absolute contraindications to methotrexate therapy.

Keywords: psoriasis, psoriatic arthropathy, alkaline phosphatase, methotrexate