To the Editor: With respect to Drs. Greaves and Weinstein'sreview article on the treatment of psoriasis (March 2 issue),1we suggest adding alcohol to the list of factors known to exacerbatepsoriasis. In men with psoriasis, the mean alcohol intake issignificantly higher than in men with other skin diseases,2the intake of alcohol is related to the severity of the disease,3and inpatient treatment is less effective in those with highalcohol intakes during the six months before admission.4 Alcoholintake also correlates with the severity of psoriasis in women.5Whether excess alcohol consumption is due to the psychologicaleffects of the disease or is an independent risk factor forpsoriasis is not known.
Deirdre A. Buckley, M.B., M.R.C.P.I. Sarah Rogers, M.Sc., F.R.C.P City of Dublin Skin and Cancer Hospital Dublin 2, Ireland
References
Greaves MW, Weinstein GD. Treatment of psoriasis. N Engl J Med 1995;332:581-588. [Free Full Text]
Poikolainen K, Reunala T, Karvonen J, Lauharanta J, Karkkainen P. Alcohol intake: a risk factor for psoriasis in young and middle aged men? BMJ 1990;300:780-783.
Monk BE, Neill SM. Alcohol consumption and psoriasis. Dermatologica 1986;173:57-60. [Medline]
Gupta MA, Schork NJ, Gupta AK, Ellis CN. Alcohol intake and treatment responsiveness of psoriasis: a prospective study. J Am Acad Dermatol 1993;28:730-732. [CrossRef][Medline]
Poikolainen K, Reunala T, Karvonen J. Smoking, alcohol and life events related to psoriasis among women. Br J Dermatol 1994;130:473-477. [CrossRef][Medline]
To the Editor: Greaves and Weinstein's recommendation that aliver biopsy be performed in patients with psoriasis beforetreatment with methotrexate is begun is outdated. There hasnever been a documented case of cirrhosis related to methotrexatetherapy,1 and all the studies linking methotrexate with liverdamage are retrospective and inconclusive.1,2 Rheumatologistshave abandoned surveillance liver biopsy in patients with rheumatoidarthritis who are being treated with methotrexate or are aboutto start such treatment.2 Many patients with psoriasis havesteatosis and nonspecific hepatocellular changes, but cirrhosisis usually absent unless they have another liver disease, suchas viral hepatitis, hemochromatosis, or alcoholic liver disease.3Percutaneous liver biopsy is not indicated in patients scheduledto be treated with methotrexate for psoriasis, unless liverdisease is anticipated on the basis of another underlying problem.
Richard A. Wright, M.D. University of Louisville School of Medicine Louisville,KY 40292
References
Kaplan MM. Methotrexate hepatotoxicity and the premature reporting of Mark Twain's death: both greatly exaggerated. Hepatology 1990;12:784-786. [Medline]
Health and Public Policy Committee, American College of Physicians. Methotrexate in rheumatoid arthritis. Ann Intern Med 1987;107:418-419.
Lanse SB, Arnold GL, Gowans JD, Kaplan MM. Low incidence of hepatotoxicity associated with long-term, low-dose oral methotrexate in treatment of refractory psoriasis, psoriatic arthritis, and rheumatoid arthritis: an acceptable risk/benefit ratio. Dig Dis Sci 1985;30:104-109. [CrossRef][Medline]
The authors reply:
To the Editor: The points raised by Drs. Buckley and Rogersand by Dr. Wright are related. As Drs. Buckley and Rogers indicate,alcohol intake may be higher in patients with psoriasis thanin patients with other skin diseases, but the evidence is weak.Dermatologists have reported a higher incidence of cirrhosisin patients with psoriasis treated with methotrexate than haverheumatologists in similarly treated patients with rheumatoidarthritis.1,2,3 The reasons for this apparent difference arenot known but might include a greater incidence of alcoholicliver injury in patients with psoriasis. Apart from the possibilityof a small increase in alcohol intake in patients with psoriasis,we have no information about other factors that might predisposepatients with psoriasis but not those with rheumatoid arthritisto methotrexate-related liver disease.
Whatever the explanation, in patients with psoriasis the likelihoodof liver disease increases in relation to the cumulative doseof methotrexate.4 Since noninvasive liver-imaging techniquesmay yield false negative results,5 we wish to emphasize theimportance of using serial liver biopsies to monitor patientswith psoriasis who are receiving long-term methotrexate treatment,as proposed in the revised guidelines for the treatment of psoriasiswith methotrexate.4 On page 586 of our article, in lines 20and 21 of the left-hand column, the text should have read "Ifcirrhosis is found," not "If methotrexate is found."
Malcolm W. Greaves, M.D., Ph.D. St. Thomas's Hospital LondonSE1 7EH, United Kingdom
Gerald D. Weinstein, M.D. University of California College ofMedicine Irvine, CA 92717-2400
References
Zachariae H, Sogaard H. Methotrexate-induced liver cirrhosis: a follow-up. Dermatologica 1987;175:178-182. [Medline]
Gilbert SC, Klintmalm G, Menter A, Silverman A. Methotrexate-induced cirrhosis requiring liver transplantation in three patients with psoriasis: a word of caution in light of the expanding use of this `steroid-sparing' agent. Arch Intern Med 1990;150:889-891. [Free Full Text]
Weinblatt ME, Kremer JM. Methotrexate in rheumatoid arthritis. J Am Acad Dermatol 1988;19:126-128. [CrossRef][Medline]
Roenigk HH Jr, Auerbach R, Maibach HI, Weinstein GD. Methotrexate in psoriasis: revised guidelines. J Am Acad Dermatol 1988;19:145-156. [Medline]
Van Ness MM, Diehl AM. Is liver biopsy useful in the evaluation of patients with chronically elevated liver enzymes? Ann Intern Med 1989;111:473-478.
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