Journal Information
Vol. 101. Issue 7.
Pages 600-613 (September 2010)
Share
Share
Download PDF
More article options
Vol. 101. Issue 7.
Pages 600-613 (September 2010)
Consensus statement
Full text access
Guidelines on the Use of Methotrexate in Psoriasis
Metotrexato: guía de uso en psoriasis
Visits
20257
G. Carreteroa,
Corresponding author
gcarrete@aedv.es

Corresponding author.
, L. Puigb, L. Dehesaa, J.M. Carrascosac, M. Riberad, M. Sánchez-Regañae, E. Daudénf, D. Vidalg, M. Alsinah, C. Muñoz-Santosh, J.L. López-Estebaranzi, J. Notarioj, C. Ferrandizc, F. Vanaclochak, M. García-Bustinduyl, R. Tabernerm, I. Belinchónn, J. Sánchez-Carazoo, J.C. Morenop, the Psoriasis Group of the Spanish Academy of Dermatology and Venereology
a Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
b Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
c Hospital Germans Trias i Pujol, Barcelona, Spain
d Hospital Universitari de Sabadell, Corporació Parc Taulí, Sabadell, Spain
e Hospital Universitario Sagrat Cor, Barcelona, Spain
f Hospital Universitario La Princesa, Madrid, Spain
g Hospital de Sant Joan Despí Moisès Broggi, Barcelona, Spain
h Hospital Clínic, Barcelona, Spain
i Hospital Fundación Alcorcón, Madrid, Spain
j Hospital Universitario de Bellvitge de Hospitalet de Llobregat, Barcelona, Spain
k Hospital 12 de Octubre, Madrid, Spain
l Hospital Universitario de Canarias, Tenerife, Spain
m Hospital Son Llàtzer, Palma de Mallorca, Islas Baleares, Spain
n Hospital General de Alicante, Alicante, Spain
o Hospital General Universitario, Valencia, Spain
p Hospital Reina Sofía, Córdoba, Spain
Ver más
This item has received
Article information
Abstract

Psoriasis, a chronic multifactorial inflammatory disease that develops in genetically predisposed individuals, affects approximately 1.5% of the Spanish population. This disease has a negative impact on patients’ quality of life, and long-term therapy is often required to control the symptoms. In addition to the classical systemic treatments (methotrexate, acitretin, cyclosporine, and ultraviolet light), the group of drugs known as biologics (etanercept, infliximab, adalimumab, and ustekinumab) provides the dermatologist with an expanded therapeutic armamentarium, thereby improving the likelihood of controlling psoriasis in patients with severe and/or extensive disease. Methotrexate, a classic antipsoriatic drug, is still very useful either as single-drug therapy or in combination with other systemic drugs, particularly as a rescue therapy or combined with biologics. This article aims to establish the role of methotrexate in the treatment of psoriasis. We considered it of interest to develop guidelines for using methotrexate in the management of psoriasis with a view to ensuring the safe and proper use of this drug in the management of psoriasis. This document was developed by consensus among members of the Psoriasis Group of the Spanish Academy of Dermatology and Venereology.

Keywords:
Methotrexate
Guidelines
Treatment
Psoriasis
Resumen

La psoriasis es una enfermedad inflamatoria crónica, de predisposición genética y origen multifactorial, que afecta aproximadamente al 1,5% de la población española, repercutiendo negativamente de forma importante en la calidad de vida de los pacientes, los cuales requieren frecuentemente tratamientos de larga duración, para controlar sus síntomas. Los tratamientos sistémicos clásicos (metotrexato, acitetrino, ciclosporina, luz ultravioleta), junto con las denominadas terapias biológicas (etanercept, infliximab, adalimumab, ustekinumab), permiten al dermatólogo disponer de un arsenal terapéutico más amplio y disponer, por lo tanto, de mayores posibilidades de control de pacientes con psoriasis severa y/o extensa. El metotrexato, un fármaco clásico en la terapia antipsoriásica, sigue siendo de gran utilidad tanto en monoterapia como asociado a otros fármacos sistémicos, en especial como rescate o combinación con los biológicos. El objetivo de este artículo es establecer el papel del metotrexato en el tratamiento de la psoriasis. Por ello hemos creído de interés elaborar una guía de uso de metotrexato en psoriasis, consensuada entre varios componentes del Grupo de Psoriasis de la Academia Española de Dermatología y Venereología, que facilite la utilización segura y precisa de este fármaco en el manejo de pacientes con psoriasis.

Palabras clave:
Metotrexato
Guía
Tratamiento
Psoriasis
Full text is only aviable in PDF
References
[1.]
R. Gubner, S. August, V. Ginsberg.
Therapeutic suppression of tissue reactivity. II. Effect of aminopterin in rheumatoid arthritis and psoriasis.
Am J Med Sci, 221 (1951), pp. 176-182
[2.]
W.F. Edmunson, W.B. Guy.
Treatment of psoriasis with folic acid antagonists.
AMA Arch Derm, 78 (1958), pp. 200-203
[3.]
B.N. Cronstein, D. Naime, E. Ostad.
The anti-inflammatory effects of methotrexate are mediated by adenosine.
Adv Exp Med, 370 (1994), pp. 411-416
[4.]
R.B. Warren, C.E.M. Griffiths.
Systemic therapies for psoriasis: methotrexate, retinoids, and cyclosporine.
Clin Dermatol, 26 (2008), pp. 438-447
[5.]
L. Genestier, R. Paillot, S. Fournel, C. Ferraro, P. Miossec, J.P. Revillard.
Immunosuppressive properties of methotrexate: apoptosis and clonal deletion of activated peripheral T cells.
J Clin Invest, 102 (1998), pp. 322-328
[6.]
A. Johnston, J.E. Gudjonsson, H. Sigmundsdottir, B.R. Ludviksson, H. Valdimarsson.
The anti-inflammatory action of methotrexate is not mediated by lymphocyte apoptosis, but by the suppression of activation and adhesion molecules.
Clin Immunol, 114 (2005), pp. 154-163
[7.]
B. Torres-Álvarez, J.P. Castanedo-Cazares, C. Fuentes-Ahumada, B. Moncada.
The effect of methotrexate on the expression of cell adhesion molecules and activation molecule CD69 in psoriasis.
J Eur Acad Dermatol Venereol, 21 (2007), pp. 334-339
[8.]
H. Sigmundsdottir, A. Johnston, J.E. Gudjonsson, B. Bjarnason, H. Valdimarsson.
Methotrexate markedly reduces the expression of vascular E-selectin, cutaneous lymphocyte-associated antigen and the numbers of mononuclear leucocytes in psoriatic skin.
Exp Dermatol, 13 (2004), pp. 426-434
[9.]
R.N. Maini, F.C. Breedveld, J.R. Kalden, J.S. Smolen, D. Davis, J.D. Macfarlane, et al.
Therapeutic efficacy of multiple intravenous infusions of anti-tumor necrosis factor alpha monoclonal antibody combined with low-dose weekly methotrexate in rheumatoid arthritis.
[10.]
S. Vermeire, M. Noman, G. Van Assche, F. Baert, G. D’Haens, P. Rutgeerts.
Effectiveness of concomitant immunosuppressive therapy in suppressing the formation of antibodies to infliximab in Crohn's disease.
Gut, 56 (2007), pp. 1226-1231
[11.]
D.W. Kress.
Etanercept therapy improves symptoms and allows tapering of other medications in children and adolescents with moderate to severe psoriasis.
J Am Acad Dermatol, 54 (2006), pp. S126-S128
[12.]
M.E. Lloyd, M. Carr, P. McElhatton, G.M. Hall, R.A. Hughes.
The effects of methotrexate on pregnancy, fertility and lactation.
QJM, 92 (1999), pp. 551-563
[13.]
R.E. Kalb, B. Strober, G. Weinstein, M. Lebwohl.
Methotrexate and psoriasis: 2009 National Psoriasis Foundation Consensus Conference.
J Am Acad Dermatol, 60 (2009), pp. 824-837
[14.]
A. Nyfords, H. Brodthagen.
Methotrexate for psoriasis in weekly oral doses without any adjunctive therapy.
Dermatologica, 140 (1970), pp. 345-355
[15.]
G.D. Weinstein, P. Frost.
Methotrexate for psoriasis. A new therapeutic schedule.
Arch Dermatol, 103 (1971), pp. 33-38
[16.]
J. Braun, P. Kästner, P. Flaxenberg, J. Währisch, P. Hanke, W. Demary, et al.
Comparison of the clinical efficacy and safety of subcutaneous versus oral administration of methotrexate in patients with active rheumatoid arthritis: results of a sixmonth, multicenter, randomized, double-blind, controlled, phase IV trial.
Arthritis Rheum, 58 (2008), pp. 73-81
[17.]
V.M. Heydendael, P.I. Spuls, B.C. Opmeer, C.A. de Borgie, J.B. Reitsma, W.F. Goldschmidt, et al.
Methotrexate versus cyclosporine in moderate-to-severe chronic plaque psoriasis.
N Engl J Med, 349 (2003), pp. 658-665
[18.]
I. Flytstrom, B. Stenberg, A. Svensson.
Methotrexate vs. ciclosporin in psoriasis: effectiveness, quality of life and safety. A randomized controlled trial.
Br J Dermatol, 158 (2008), pp. 116-121
[19.]
J.H. Saurat, G. Stingl, L. Dubertret, K. Papp, R.G. Langley, J.P. Ortonne, et al.
Efficacy and safety results from the randomized controlled comparative study of adalimumab vs. methotrexate vs. placebo in patients with psoriasis (CHAMPION).
Br J Dermatol, 158 (2008), pp. 558-566
[21.]
J. Schmitt, Z. Zhang, G. Wozel, M. Meurer, W. Kirch.
Efficacy and tolerability of biologic and nonbiologic systemic treatments for moderate-to-severe psoriasis: meta-analysis of randomized controlled trials.
Br J Dermatol, 159 (2008), pp. 513-526
[22.]
N. Bansback, S. Sizto, H. Sun, S. Feldman, M.K. Willian, A. Anis.
Efficacy of systemic treatments for moderate to severe plaque psoriasis: systematic review and meta-analysis.
Dermatology, 219 (2009), pp. 209-218
[23.]
D. Pathirana, A.D. Ormerod, P. Saiag, C. Smith, P.I. Spuls, A. Nast, et al.
European S3-Guidelines on the systemic treatment of psoriasis vulgaris.
J European Acad Dermatol, 23 (2009), pp. 5-70
[24.]
R.J. Van Dooren-Greebe, A.L. Kuijpers, J. Mulder, T. De Boo, P.C. Van de Kerkhof.
Methotrexate revisited: effects of long-term treatment in psoriasis.
Br J Dermatol, 130 (1994), pp. 204-210
[25.]
U.F. Haustein, M. Rytter.
Methotrexate in psoriasis: 26 years experience with low-dose long-term treatment.
J Eur Acad Dermatol Venereol, 14 (2000), pp. 382-388
[26.]
J. Lucas, E. Ntuen, D.J. Pearce, A.B. Fleischer, S.R. Feldman.
Methotrexate: Understanding the risk in psoriasis patients.
J Dermatolog Treat, 1 (2009), pp. 1-3
[27.]
R.J. McKendry.
The remarkable spectrum of methotrexate toxicities.
Rheum Dis Clin North Am, 23 (1997), pp. 939-954
[28.]
A.E. Van Ede, R.F. Laan, M.J. Rood, T.W. Huizinga, M.A. van de Laar, C.J. van Denderen, et al.
Effect of folic or folinic acid supplementation on the toxicity and efficacy of methotrexate in rheumatoid arthritis: a forty-eight week, multicenter, randomized, double-blind, placebo-controlled study.
[29.]
A. MacDonald, A.D. Burden.
Noninvasive monitoring for methotrexate hepatotoxicity.
Br J Dermatol, 152 (2005), pp. 405-408
[30.]
Agencia Española de Medicamentos y Productos Sanitarios (AEMPS). Posible confusión en la dosis de metotrexato administrado por vía oral. Información Terapéutica del Sistema Nacional de Salud vol. 28-No. 6-2004.
[31.]
Improving compliance with oral methotrexate guidelines. Available from: http://www.nrls.npsa.nhs.uk/resources/patient-safety-topics. [Cited February 22, 2010], [updated 1/1/2007].
[32.]
R.B. Warren, Smith., E. Campalani, S. Eyre, C.H. Smith, J.N. W.N. Barker, et al.
Outcomes of methotrexate therapy for psoriasis and relationship to genetic polymorphisms.
Br J Dermatol, 160 (2009), pp. 438-441
[33.]
T. Dervieux, D. Orentas, J. Marcelletti, K. Pischel, K. Smith, M. Walsh, et al.
HPLC determination of erythrocyte methotrexate polyglutamates after low-dose methotrexate therapy in patients with rheumatoid arthritis.
Clin Chem, 49 (2003), pp. 1632-1641
[34.]
E. Campalani, M. Arenas, A.M. Marinaki, C.M. Lewis, J.N. Barker, C.H. Smith.
Polymorphisms in folate, pyrimidine, and purine metabolism are associated with efficacy and toxicity of methotrexate in psoriasis.
J Invest Dermatol, 127 (2007), pp. 1860-1867
[35.]
R.B. Warren, R.L. Smith, E. Campalani, C.H. Smith, J.N. Barker, J. Worthington, et al.
Genetic variation in efflux transporters influences outcome to methotrexate therapy in patients with psoriasis.
J Invest Dermatol, 128 (2008), pp. 1925-1929
[36.]
M. Hroch, J. Chladek, M. Simkova, J. Vaneckova, J. Grim, J. Martinkova.
A pilot study of pharmacokinetically guided dosing of oral methotrexate in the initial phase of psoriasis treatment.
J Eur Acad Dermatol Venereol, 22 (2008), pp. 19-24
[37.]
J. Chládek, M. Simková, J. Vanecková, M. Hroch, J. Jirina Chládkova, J. Martínková, et al.
The effect of folic acid supplementation on the pharmacokinetics and pharmacodynamics of oral methotrexate during the remission-induction period of treatment for moderate-to-severe plaque psoriasis.
Eur J Clin Pharmacol, 64 (2008), pp. 347-355
[38.]
S.A. Alkins, J.C. Byrd, S.K. Morgan, F.T. Ward, R.B. Weiss.
Anaphylactoid reactions to methotrexate.
[39.]
H.H. Roenigk, R. Auerbach, H. Maibach, G. Weinstein, M. Lebwohl.
Methotrexate in psoriasis: consensus conference.
J Am Acad Dermatol, 38 (1998), pp. 478-485
[40.]
J.M. Kremer, G.S. Alarcón, R.W. Lightfoot, R.F. Willkens, D.E. Furst, H.J. Williams, et al.
Methotrexate for rheumatoid arthritis. Suggested guidelines for monitoring liver toxicity. American College of Rheumatology.
Arthritis Rheum, 37 (1994), pp. 316-328
[41.]
M.A. Berends, J. Snoek, E.M. de Jong, P.C. van de Kerkhof, M.G. van Oijen, J.H. van Krieken, et al.
Liver injury in long-term methotrexate treatment in psoriasis is relatively infrequent.
Aliment Pharmacol Ther, 24 (2006), pp. 805-811
[42.]
J.S. Henning, L.M. Gruson, B.E. Strober.
Reconsidering liver biopsies during methotrexate therapy.
J Am Acad Dermatol, 56 (2007), pp. 893-894
[43.]
P. Gisondi, G. Targher, G. Zoppini, G. Girolomoni.
Non-alcoholic fatty liver disease in patients with chronic plaque psoriasis.
J Hepatol, 51 (2009), pp. 758-764
[44.]
I.J. Hickman, G.A. Macdonald.
Impact of diabetes on the severity of liver disease.
Am J Med, 120 (2007), pp. 829-834
[45.]
K. Lindsay, A.D. Fraser, A. Layton, M. Goodfield, H. Gruss, A. Gough.
Liver fibrosis in patients with psoriasis and psoriatic arthritis on long-term, high cumulative dose methotrexate therapy.
Rheumatology (Oxford), 48 (2009), pp. 569-572
[46.]
R.J. Chalmers, B. Kirby, A. Smith, P. Burrows, R. Little, M. Horan, et al.
Replacement of routine liver biopsy by procollagen III aminopeptide for monitoring patients with psoriasis receiving long-term methotrexate: a multicenter audit and health economic analysis.
Br J Dermatol, 152 (2005), pp. 444-450
[47.]
P.D. Maurice, A.J. Maddox, C.A. Green, F. Tatnall, J.K. Schofield, D.J. Stott.
Monitoring patients on methotrexate: hepatic fibrosis not seen in patients with normal serum assays of aminoterminal peptide of type III procollagen.
Br J Dermatol, 152 (2005), pp. 451-458
[48.]
D. Laharie, F. Zerbib, X. Adhoute, X. Boué-Lahorgue, J. Foucher, L. Castéra, et al.
l. Diagnosis of liver fibrosis by transient elastography (FibroScan) and non-invasive methods in Crohn's disease patients treated with methotrexate.
Aliment Pharmacol Ther, 23 (2006), pp. 1621-1628
[49.]
M.A. Berends, J. Snoek, E.M. de Jong, J.H. Van Krieken, R.J. de Knegt, M.G. van Oijen, et al.
Biochemical and biophysical assessment of MTX-induced liver fibrosis in psoriasis patients: Fibrotest predicts the presence and Fibroscan predicts the absence of significant liver fibrosis.
[50.]
S. Khan, D. Subedi, M.M.U. Chowdhury.
Use of amino terminal type III procollagen peptide assay in methotrexate therapy for psoriasis.
Postgrad Med J, 82 (2006), pp. 353-354
[51.]
J.M. Kremer, G.S. Alarcón, M.E. Weinblatt, N.I.V. Haymakcian, M. Macaluso, G.V. Cannon, et al.
Clinical, laboratory, radiographic, and histopathologic features of methotrexate-associated lung injury in patients with rheumatoid arthritis.
[52.]
D. Sáenz Abad, F.J. Ruiz-Ruiz, S. Monón Ballarín, J. Mozota Duarte, A. Marquina Barcos.
Neumonitis secundaria a metotrexate.
Ann Med Intern, 25 (2008), pp. 27-30
[53.]
P. Hillquin, X. Renoux, X. Perrot, S. Puechal, C.L. Menkes.
Occurrence of pulmonary complications during methotrexate therapy in rheumatoid arthritis.
Br J Rheum, 35 (1996), pp. 441-445
[54.]
G.S. Alarcon, A. Kremer, M. Macaluso, M.E. Weinblatt, G.W. Cannon, W.R. Palmer, et al.
Risk factors for methotrexate-induced lung injury in patients with rheumatoid arthritis: A multicenter, case-control study.
Ann Intern Med, 127 (1997), pp. 356-364
[55.]
E. From.
Methotrexate pneumonitis in a psoriatic.
Br J Dermatol, 93 (1975), pp. 107-110
[56.]
A.J. Kinder, A.B. Hassell, J. Brand, A. Brownfield, M. Grove, M.F. Shadforth.
The treatment of inflammatory arthritis with methotrexate in clinical practice: treatment duration and incidence of adverse drug reactions.
Rheumatology, 44 (2005), pp. 61-66
[57.]
J. Belzunegui, J.J. Intxausti, J.R. De Dios, L. López-Domínguez, R. Queiro, C. González, et al.
Absence of pulmonary fibrosis in patients with psoriatic arthritis treated with weekly low-dose methotrexate.
Clin Exp Rheumatol, 19 (2001), pp. 727-730
[58.]
J.K. Dawson, D.R. Graham, J. Desmond, H.E. Fewins, M.P. Lynch.
Investigation of the chronic pulmonary effects of low-dose oral methotrexate in patients with rheumatoid arthritis: a prospective study incorporating HRCT scanning and pulmonary function tests.
Rheumatology (Oxford), 41 (2002), pp. 262-267
[59.]
L. Puig, X. Bordas, J.M. Carrascosa, E. Dauden, C. Ferrándiz, J.M. Hernánz, et al.
Documento de Consenso sobre la evaluación y el tratamiento de la psoriasis moderada/grave del Grupo Español de Psoriasis de la Academia Española de Dermatología y Venereología.
Actas Dermosifiligr, 100 (2009), pp. 277-286
[60.]
L. Dubertret, S. Climenti, E. Christophers, E. Dauden, M. de Rie, C. E.M. Griffiths, et al.
Alice, Éloi, Magali and Robert: the lives of four patients with psoriasis and the therapeutic approaches of eight European experts.
Br J Dermatol, 161 (2009), pp. 1-30
[61.]
Available from: https://sinaem4.agemed.es/consaem/METOTREXATO. [Cited February 17, 2010].
[62.]
S. Prey, C. Paul.
Effect of folic or folinic acid supplementation on methotrexate-associated safety and efficacy in inflammatory disease: a systematic review.
Br J Dermatol, 160 (2009), pp. 622-628
[63.]
T.A. Goodman, R.P. Polisson.
Methotrexate: adverse reactions and major toxicities.
Rheum Dis Clin North Am, 20 (1994), pp. 513-528
[64.]
A.E. van Ede, R.F. Laan, M.J. Rood, T.W. Huizinga, M.A. van de Laar, C.J. van Denderen, et al.
Effect of folic or folinic acid supplementation on the toxicity and efficacy of methotrexate in rheumatoid arthritis: a forty-eight week, multicenter, randomized, double-blind, placebo-controlled study.
[65.]
A. Salim, E. Tan, A. Ilchyshyn, J. Berth-Jones.
Folic acid supplementation during treatment of psoriasis with methotrexate: a randomized, double-blind, placebo-controlled trial.
Br J Dermatol, 154 (2006), pp. 1169-1174
[66.]
R. Manna, R.M. Verrechia, M. Diaco, M. Montalto, G. Cammarota, G. Gasbarrini.
Folic acid supplementation during methotrexate treatment: nonsense?.
Rheumatology, 43 (2004), pp. 267-271
[67.]
J.E. Baggott, S.L. Morgan.
Methotrexate catabolism to 7-hydroxymethotrexate in rheumatoid arthritis alters drug efficacy and retention and is reduced by folic acid supplementation.
Arthritis Rheum, 60 (2009), pp. 2257-2261
[68.]
P.C.M. Van de Kerkhof.
Therapeutic strategies: rotational therapy and combinations.
Clin Exp Dermatol, 26 (2001), pp. 3 56-361
[69.]
F. Aydin, T. Canturk, N. Senturk, A.Y. Turanli.
Methotrexate and ciclosporin combination for the treatment of severe psoriasis.
Clin Exp Dermatol, 31 (2006), pp. 520-524
[70.]
C.M. Clark, B. Kirby, A.D. Morris, S. Davison, I. Zaki, R. Emerson, et al.
Combination treatment with methotrexate and ciclosporin for severe recalcitrant psoriasis.
Br J Dermatol, 141 (1999), pp. 279-282
[71.]
P. Asawanonda, Y. Nateetongrungsak.
Methotrexate plus narrowband UVB phototherapy versus narrowband UVB phototherapy alone in the treatment of plaque-type psoriasis: a randomized, placebo-controlled study.
J Am Acad Dermatol, 54 (2006), pp. 1013-1018
[72.]
K.E. Lowenthal, P.J. Horn, R.E. Kalb.
Concurrent use of methotrexate and acitretin revisited.
J Dermatolog Treat, 19 (2008), pp. 22-26
[73.]
W.G. Stebbins, M.G. Lebwohl.
Biologics in combination with nonbiologics: efficacy and safety.
Dermatol Ther, 17 (2004), pp. 432-440
[74.]
J.C. Cather, A. Menter.
Combining traditional agents and biologics for the treatment of psoriasis.
Semin Cutan Med Surg, 24 (2005), pp. 37-45
[75.]
U. Klotz, A. Teml, M. Schwab.
Clinical pharmacokinetics and use of infliximab.
Clin Pharmacokinet, 46 (2007), pp. 645-660
[76.]
C. Zachariae, N.J. Mørk, T. Reunala, H. Lorentzen, E. Falk, S.L. Karvonen, et al.
The combination of etanercept and methotrexate increases the effectiveness of treatment in active psoriasis despite inadequate effect of methotrexate therapy.
Acta Derm Venereol, 88 (2008), pp. 495-500
[77.]
R.J. Driessen, P.C. van de Kerkhof, E.M. de Jong.
Etanercept combined with methotrexate for high-need psoriasis.
Br J Dermatol, 159 (2008), pp. 460-463
[78.]
D.D. Gladman, P.J. Mease, C.T. Ritchlin, E.H. Choy, J.T. Sharp, P.A. Ory, et al.
Adalimumab for long-term treatment of psoriatic arthritis: forty-eight week data from the adalimumab effectiveness in psoriatic arthritis trial.
Arthritis Rheum, 56 (2007), pp. 476-488
[79.]
R.B. Warren, R.J.G. Chalmers, C.E.M. Griffiths, A. Menter.
Methotrexate for psoriasis in the era of biological therapy.
Clin Exp Dermatol, 33 (2008), pp. 551-554
Copyright © 2010. Academia Española de Dermatología y Venereología and Elsevier España, S.L.
Download PDF
Idiomas
Actas Dermo-Sifiliográficas
Article options
Tools
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?