Treatment of bullous pemphigoid with low-dose methotrexate

Three patients with biopsy-proven bullous pemphigoid (BP) and anti-basement-membrane antibodies were treated weekly with low-dose methotrexate (MTX) 12,5-25 mg. To accelerate recovery we initially combined MTX with systemic and/or topical corticosteroids. In combination with MTX, the initial dose of 32 mg corticosteroids/day was sufficient. In all 3 patients the BP disappeared within 4 weeks. To maintain this beneficial effect, very low doses of MTX (25 mg every other week or every four weeks) suffered. Opportunistic infections did not appear. Laboratory tests during MTX-treatment revealed no immunosuppression. The treatment was well tolerated; we could neither observe subjective problems nor other pathologic changes. There are several lines of evidence for immunomodulating effects of MTX and the clinical benefit in BP might be possibly due to these actions of MTX. Our data show, that the treatment of BP with low-dose MIX is an effective alternative with a favorable benefit/side-effect ratio.