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Methotrexate (MTX) is an antirheumatic drug used worldwide in many indications of chronic inflammation and autoimmunity including psoriasis.1 In principle, it is safe if monitored carefully and has major cost-effective therapeutic benefits.2 Major adverse events for MTX are related to the folate antagonism and primarily affect highly proliferative tissues such as bone marrow and gastrointestinal mucosa.3 Life-threatening myelosuppression leading to sepsis with potential fatal outcome is the most serious complication of MTX treatment that may occur despite regular dose administration.4 By analyzing 3 cases of myelosuppression during low-dose MTX treatment with mucocutaneous manifestations, we find that impaired renal elimination to be the leading cause of MTX toxicity and identify the different durations of plasma and intracellular half-lives of MTX as the main reason for bone marrow suppression in spite of normal MTX trough levels.

Febrile ulceronecrotic Mucha-Habermann disease (FUMHD) is a rare, potentially fatal, severe variant of pityriasis lichenoides et varioliformis acuta (PLEVA). Lesions of FUMHD usually start with erythematous papules and plaques that rapidly progress to form large, often coalescing necrotic ulcers with hemorrhagic crusts. The skin findings are typically accompanied by systemic symptoms including high fever, abdominal pain, diarrhea, arthritis, pulmonary involvement, central nervous system symptoms, and sepsis. These systemic manifestations can lead eventually to serious complications or even a fatal outcome.1, 2, 3 Fatal cases were confined to adults (9 deaths of about 70 reported cases). On the contrary, children with FUMHD tend to have a more favorable outcome than adults, and no deaths have so far been reported in children.2, 3 Here we report the first case, to our knowledge, of a child with FUMHD complicated by sepsis that resulted in multiple organ failure and death.

For more than 30 years, methotrexate (MTX) has been a mainstay in the treatment of various inflammatory disorders including rheumatoid arthritis (RA) and psoriasis.1 Off-label use of MTX has expanded in recent years, as it is found to be effective in treating dermatoses such as atopic dermatitis, bullous pemphigoid, pemphigus vulgaris, and mycosis fungoides.1 Because of its common use in dermatology, the oncogenic potential of MTX is of special significance for the clinician interested in prescribing this drug.1 Although MTX has been implicated in squamous cell carcinoma in patients treated for psoriasis, its potential to induce lymphoma is controversial, as studies find either an increase or no clinically significant increase in malignant potential with chronic MTX use.1 Herein, we report a case of a CD30+ T-cell lymphoproliferative disorder (LPD) of the lip and oral cavity in a patient taking MTX for RA.

An association between mycosis fungoides (MF) and neutrophilic dermatoses (ND) is rare. We describe a case of long-duration stage IIB MF developing pyoderma gangrenosum-like lesions and neutrophilic hidradenitis with histologic findings suggestive of necrotizing vasculitis.