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Background: Pityriasis rubra pilaris (PRP) is a rare disease that is difficult to manage. Treatment options include corticosteroids, immunomodulatory drugs, and biologics. Available literature has primarily described the use of weekly dosing of methotrexate, but there is limited data investigating the effectiveness of daily low-dose methotrexate in PRP treatment. Methods: A retrospective cohort study was conducted from September 2010 to December 2019 to determine the effectiveness of daily low-dose methotrexate in treating PRP. Results: The average duration of follow-up was 13.5 months. 14 patients were treated with oral daily low-dose methotrexate. 13 patients (92.9%) showed improvement on oral daily low-dose methotrexate. Mean time to clinical response was 5.9 weeks. In seven patients (50%), complete response on methotrexate monotherapy occurred within an average of 11.9 months. 12 patients (85.7%) developed asymptomatic transaminitis that resolved in most patients (66.7%) after dose reduction. Conclusions: In this study, daily low-dose methotrexate was an effective treatment of PRP and may be considered in patients unresponsive to weekly dosing. Due to the high incidence of transaminitis, the authors recommend frequent lab monitoring and screening for risk factors. Further studies are warranted to elucidate the efficacy of daily low-dose methotrexate in the management of PRP.

Background: Diffuse dermal angiomatosis (DDA) is a rare, reactive vascular disorder of the skin. Association with vascular disease, smoking, and large pendulous breasts has been reported. No standard of care exists but benefit with medication and reduction mammaplasty has been reported. Methods: We report a case of a 49-year-old obese female with a history of smoking who presented with DDA that improved with smoking cessation and pentoxifylline prior to reduction mammaplasty. We also performed a retrospective chart review of all patients with DDA seen at our institution between 2010 and 2020. Results: Eight female patients with DDA affecting the breasts were evaluated at our institution. The mean age was 49.5 years. Five of the patients noted symptoms at presentation. Obesity was seen in 7 (87.5%) patients and 5 (63%) had a smoking history. There was no significant difference between symptomatic and asymptomatic groups in regard to age, t4=-0.63, p=0.56, but BMI trended higher in the symptomatic group, t6=2.27, p=0.06. Three patients (38%) were noted to have fibromyalgia. All symptomatic patients saw improvement in their symptoms with treatments including reduction mammaplasty (1 patient), aspirin (1 patient), pentoxifylline (3 patients), smoking cessation (2 patients), and/or weight loss (1 patient). Conclusions: Our series is the second largest series of DDA of the breasts and confirms many reported associations including obesity, smoking, and large pendulous breasts. We report the first known case of improvement with weight loss as a sole intervention, as well as identify a novel potential association between DDA and fibromyalgia.