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What’s the Right Dose of Methotrexate?
from Sarah P.

Hey there.  This is all very new to me, relatively.  I have had severe palmo-plantar pustular psoriasis since June of last year.  Been on various treatments, including every cream imaginable, coal tar, oral steroids, UVB treatments, Elidel, etc.  The biopsy has actually come back saying “Indeterminate:  psoriasis/eczema: traits of both.” 

My question is, as a person who is on oral steroids (weaning off) and MTX (7.5 mg/wk), what is the usual effective dose of MTX?  My doctor is wonderful, but often doesn't try things until I mention them.  Hence, the start of MTX about 6 weeks ago. 

I'm now on every-other-day oral prednisone 20 mg but I can feel once that 48 hours is coming to a close!  Little bubbles start to form under the skin, and go away within a few hours of taking my miracle pill.  Prednisone is the ONLY thing that has worked, and I think it might be easier to wean off of with a higher MTX dosage...what's your opinion?

Thanks:  -Sarah

*****

Ed’s Response:  High, Sarah.  If you've been on 7.5 mgs/wk for 6 weeks with no noticeable improvement, you might want to ask your derm about a larger dose.  Everyone is different.  I was taking 25 mgs/wk standard and 30, for a few weeks, to initiate clearance.  Many derms like to start people off with low dosages and work up to what it takes.  Since the toxicity of MTX is cumulative-dose dependent, no one wants to take more than they need.  However, there are lots of reasons why docs might want to keep your dose low. 

On the other hand, I’ve heard of NO derm who wants to keep a flaker on oral prednisone.  I’m not a derm, but I think most would say finding a dose level for MTX that works, and getting off the oral prednisone altogether, would be the better bet.  Keep us apprised.  -Ed

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