Benefits

There are no systematic reviews or RCTs of the role of methotrexate in the treatment of cutaneous sarcoidosis.40,41 Baughman et al40 performed a double-blind placebo-controlled trial investigating whether methotrexate was steroid sparing in acute sarcoidosis. Although the study included three patients with skin manifestations of sarcoidosis, the results did not include information on whether the lesions had resolved, so no conclusions can be drawn from this study regarding the efficacy of methotrexate for this indication. Several open non-randomised non-controlled studies have been published. Veien et al41 conducted the first study of methotrexate for cutaneous sarcoidosis, and found that in 12 of 16 patients, skin lesions cleared with 25 mg/week. Two patients discontinued the medicine because of nausea. Lower et al42 reported on 55 patients with symptomatic sarcoidosis who were treated with methotrexate (average dose 28 mg/day) for over 2 years as a steroid-sparing agent. Clinical response was measured by improvement in affected organs and reduction in use of steroids. Sixteen of the 17 patients with cutaneous lesions had improvement of their lesions while taking methotrexate. Kaye et al43 report on five patients with severe steroid-resistant sarcoidosis treated with methotrexate, 10 mg/week, for 30 months. Of the four patients with skin lesions, three had at least 60% regression, and one had complete regression of lesions with methotrexate. Gedalia et a/.44 presented the results of methotrexate, 10-15 mg/week, in seven paediatric patients with sarcoidosis. Of the three patients with cutaneous lesions, two had resolution of their skin findings with methotrexate. Mean dose of prednisone for all study participants was tapered from an average of 49 mg/day to 7-3 mg/day at 6 months.44 Lacher45 published the first case report of methotrexate for cutaneous sarcoidosis, describing a patient in whom prednisone failed, but who responded to a combination of prednisone, 75 mg three times weekly, and methotrexate, 40 mg twice weekly. The dose of prednisone was eventually tapered and the patient maintained on methotrexate, 7-5 mg twice weekly. Webster et al.46 presented case reports on three patients who had improvement of their severe steroid-resistant cutaneous sarcoidosis with methotrexate, 15-22-5 mg/week. Henderson et al.47 presented a case report of a man with steroid-resistant laryngeal and cutaneous sarcoidosis who responded to methotrexate, 10 mg/week.

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