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IMPORTANCE: A clear dosing regimen for methotrexate in psoriasis is lacking, and this might lead to a suboptimal treatment. Because methotrexate is affordable and globally available, a uniform dosing regimen could potentially optimize the treatment of patients with psoriasis worldwide. OBJECTIVE: To reach international consensus among psoriasis experts on a uniform dosing regimen for treatment with methotrexate in adult and pediatric patients with psoriasis and identify potential future research topics. DESIGN, SETTING, AND PARTICIPANTS: Between September 2020 and March 2021, a survey study with a modified eDelphi procedure that was developed and distributed by the Amsterdam University Medical Center and completed by 180 participants worldwide (55 [30.6%] resided in non-Western countries) was conducted in 3 rounds. The proposals on which no consensus was reached were discussed in a conference meeting (June 2021). Participants voted on 21 proposals with a 9-point scale (1-3 disagree, 4-6 neither agree nor disagree, 7-9 agree) and were recruited through the Skin Inflammation and Psoriasis International Network and European Academy of Dermatology and Venereology in June 2020. Apart from being a dermatologist/dermatology resident, there were no specific criteria for participation in the survey. The participants worked mainly at a university hospital (97 [53.9%]) and were experienced in treating patients with psoriasis with methotrexate (163 [91.6%] had more than 10 years of experience). MAIN OUTCOMES AND MEASURES: In a survey with eDelphi procedure, we tried to reach consensus on 21 proposals. Consensus was defined as less than 15% voting disagree (1-3). For the consensus meeting, consensus was defined as less than 30% voting disagree. RESULTS: Of 251 participants, 180 (71.7%) completed all 3 survey rounds, and 58 participants (23.1%) joined the conference meeting. Consensus was achieved on 11 proposals in round 1, 3 proposals in round 2, and 2 proposals in round 3. In the consensus meeting, consensus was achieved on 4 proposals. More research is needed, especially for the proposals on folic acid and the dosing of methotrexate for treating subpopulations such as children and vulnerable patients. CONCLUSIONS AND RELEVANCE: In this eDelphi consensus study, consensus was reached on 20 of 21 proposals involving methotrexate dosing in patients with psoriasis. This consensus may potentially be used to harmonize the treatment with methotrexate in patients with psoriasis.

Erythema induratum, an inflammation of the blood vessels of the skin that occurs in women, is characterized by hard skin growths that break down to form ulcers and decaying scars. The cause of erythema induratum has not been clearly established, but in 1861, Bazin described the skin changes in relation to tuberculosis, an infectious disease caused by the tubercle bacillus, Mycobacterium tuberculosis. Several studies have since suggested that erythema induratum does not originate from tuberculosis. The clinical findings and physical nature of tissues were analyzed in 26 cases of erythema induratum. The characteristic skin lesions on the legs of middle-aged women were purplish, hardened growths, one to two centimeters in diameter, painful and sometimes ulcerated; after healing, the affected skin area developed scars. The diagnosis of tuberculosis was confirmed with positive results on the Mantoux test, a skin test for tuberculosis. In addition, the lesions cleared after treatment with antituberculosis agents. Tissue examination revealed inflammation of the blood vessels and of the fatty connective tissue. The findings suggest that erythema induratum results from tuberculosis. (Consumer Summary produced by Reliance Medical Information, Inc.)

Atopic dermatitis is an increasingly prevalent common childhood disease. While the majority of patients have mild disease, atopic dermatitis can cause considerable distress to patients and their caregivers, with significant social and financial cost to families. With a prevalence of 15 - 20% in Western countries, atopic dermatitis also has a considerable health and societal cost to the community. Many new treatments have been shown to be therapeutically effective, particularly in severe disease, including cyclosporin A (Neoral®, Novartis AG), interferon, tacrolimus (Fujisawa Pharmaceutical Co. Ltd.) and iv. immunoglobulin. These are expensive when compared to standard treatments like emollients and topical corticosteroids and have significant adverse effects that limit their use. Additional costs related to monitoring are incurred and the long-term safety of these treatments is yet to be determined. However, an advantage over more traditional therapies is their ability to produce benefits even after treatment ceases. Treatments that produce long-term remissions have a greater likelihood of being cost-effective. With monetary constraints on healthcare and the importance governments place on reducing drug costs, economic evaluations are becoming an increasingly important factor for drug acceptance. Those evaluating cost-effectiveness should pay particular attention to the potential reduction in indirect and intangible costs. Unfortunately, there is a dearth of cost-effectiveness studies in atopic eczema and this needs to be addressed with some urgency.

Intravenous immunoglobulin (IVIg) is standard therapy for primary immunodeficiencies, Kawasaki Disease and idiopathic thrombocytopenic purpura. More recently, the use of high dose IVIg (2 g/kg in divided doses) has widened to include a number of inflammatory diseases, including atopic eczema. The mechanism of IVIg’s anti-inflammatory action has yet to be fully understood. Proposed mechanisms include modulation of IgE responses and a reduction in inflammatory cytokines with a reduction in T-cell proliferation. Antibacterial and antitoxin effects may also play a role.

In the last 2 years, there has been interest in the relationship between hepatitis C virus (HCV) infection and porphyria cutanea tarda (PCT). Accordingly, we were concerned with identifying any of our patients with PCT who may have HCV infection so as to offer counseling and treatment. Patients known to suffer from PCT were contacted through outpatient appointments or by correspondence and were asked to provide a serum specimen for HCV analysis and measurement of alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, γ-glutamyltransferase, protein, and albumin concentrations, and for a complete blood cell count. Of the 25 patients traced, none were found to have evidence of active HCV infection. This included six members of a single family with familial PCT. Serum samples were screened for antibody to HCV using an enzyme-linked immunosorbent assay. Test results were positive in one patient, but amplification of HCV RNA followed by Southern blotting and hybridizing