Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 Feb;39(2):331-339.
doi: 10.1111/jdv.20271. Epub 2024 Aug 1.

International consensus on methotrexate dosing for patients with atopic dermatitis: An eDelphi study

Anouk G M Caron  1   2 , Astrid M van Huizen  1   2 , Annelie A H Musters  1   2 , Louise A A Gerbens  1   2 , Maritza A Middelkamp Hup  1   2 , Carsten Flohr  3 , Alan D Irvine  4 , Christian Vestergaard  5 , Ketty Peris  6   7 , Heather A Brandling-Bennett  8 , Aaron M Drucker  9 , Phyllis I Spuls  1   2 ; MTX Consensus for AD Survey Study Group
Collaborators, Affiliations

International consensus on methotrexate dosing for patients with atopic dermatitis: An eDelphi study

Anouk G M Caron et al. J Eur Acad Dermatol Venereol. 2025 Feb.

Erratum in

Abstract

Background: Despite the widespread off-label use of methotrexate (MTX) for the treatment of atopic dermatitis (AD), there is limited high-quality evidence on dosing regimens and existing guidelines do not provide clear recommendations regarding dosing strategies.

Objective: The aim of this study was to achieve international consensus among AD experts to standardize the dosing regimen for MTX treatment in adults and children with AD.

Methods: An electronic Delphi (eDelphi) study was conducted from October 2021 to September 2022. Recruitment was conducted through dermatology societies and AD interest groups. Participation was open to dermatologists and dermatology residents experienced in treating AD patients with MTX. The study consisted of three online rounds. The first round was informed by a systematic review of relevant literature, and subsequent rounds were adjusted based on the results of the previous round. Participants voted on 19 proposals using a 9-point scale (1-3 disagree, 4-6 neither agree nor disagree, 7-9 agree). Consensus was achieved when at least 70% of participants agreed, and less than 15% disagreed. Proposals that did not reach consensus in the first three rounds were discussed in a consensus meeting, where consensus was defined as less than 30% disagreement.

Results: In total, 152 participants completed Round 1, 104 (68%) completed all survey rounds, and 43 (28%) joined the consensus meeting. Consensus was achieved on 7 proposals in Round 1, 4 in Round 2 and 6 in Round 3. The final 2 proposals reached consensus during the consensus meeting. Consensus topics include test dose, start dose, maximum dose, administration route, dosing schedule, management of stopping treatment, treatment duration and folic acid supplementation.

Conclusions: This eDelphi study achieved consensus on 19 proposals related to MTX dosing for adults and children with AD. These results aim to guide prescribing decisions and encourage a standardized global approach to MTX use in AD.

PubMed Disclaimer

Conflict of interest statement

Phyllis I. Spuls received departmental independent research grants for the TREAT NL registry from Pharma since December 2019. She is engaged in conducting clinical trials with several pharmaceutical industries producing drugs for treating conditions such as psoriasis and atopic dermatitis. Compensation is provided to the department/hospital for these endeavours. She is Chief Investigator (CI) of the systemic and phototherapy atopic eczema registry (TREAT NL) for adults and children. P.I. She applied for and received a grant to execute this study from the European Academy of Dermatology and Venereology. Louise A.A. Gerbens is one of the main investigators of the TREAT NL registry and is an author of the EuroGuiDerm guideline. She also received Governmental funding of the UPDATE trial (ZonMw) (not related to current project). Anouk G.M. Caron, Astrid M. van Huizen and Annelie H. Musters served as a subinvestigators in clinical trials and observational studies for AbbVie and Janssen and as a subinvestigators for the TREAT NL registry. Aaron M. Drucker has received compensation from the British Journal of Dermatology (reviewer and Section Editor), American Academy of Dermatology (guidelines writer), Canadian Dermatology Today (manuscript writer) and National Eczema Association (consultant) Canadian Agency for Drugs and Technologies in Health (consultant). Dr. Drucker has received research grants to his institution from the National Eczema Association, Eczema Society of Canada, Canadian Dermatology Foundation, Canadian Institutes for Health Research, US National Institutes of Health and Physicians Services Incorporated Foundation. He is president of the American DermatoEpidemiology Network, Vice Chair of the National Eczema Association Scientific and Medical Advisor Committee and Chair of the American Academy of Dermatology Atopic Dermatitis Expert Resource group. Ketty Peris reports grant and personal fees as advisory board from Abbvie, Almirall, Beiersdorf, Boehringer, Bristol MS, Galderma, Lilly, Sanofi, Sunpharma and Philogen, outside the submitted work. She is a Member of Board Directors of the Catholic University in Milan. Christian Vestergaard has received honoraria from Novartis, Abbvie, Leo Pharma, Sanofi, GSK, Pierre Fabre and Almirall and Unrestricted research grants from Novartis, Sanofi and LEO pharma and worked as Investigator for Novartis, Abbvie, Sanofi and Almirall. He is President of the Nordic Dermatology Association. Maritza (Pina) A. Middelkamp Hup received departmental independent research grants from Pharma since December 2019 for the TREAT NL registry and is investigator of the TREAT NL registry, received a departmental independent research grant from the BIOMAP project and is part of the BIOMAP consortium, on the Dutch advisory board of Sanofi. Carsten Flohr is Chief Investigator of the UK National Institute for Health Research‐funded TREAT and SOFTER (Clinicaltrials.gov: NCT03270566) trials as well as the UK‐Irish Atopic eczema Systemic Therapy Register (A‐STAR; ISRCTN11210918) and a Principle Investigator in the European Union (EU) Horizon 2020‐funded BIOMAP Consortium. He also leads the EU Trans‐Foods consortium. His department has received funding from Sanofi‐Genzyme and Pfizer for skin microbiome work. He has also received compensation from the British Journal of Dermatology (reviewer and Section Editor) and EuroGuiDerm (guidelines lead). Alan Irvine has received honoraria for consultancy from AbbVie, Almirall, Aslan, LEO Pharma, Lilly, Novartis, Pfizer, RAPT, Regeneron and Sanofi. He is president of the International Eczema Council. Heather A. Brandling‐Bennett is Vice President of the Society for Pediatric Dermatology and Board Member of the Washington State Dermatology Association.

Figures

FIGURE 1
FIGURE 1
Overview of the eDelphi process. Note: Figure illustrates the structure of the eDelphi process. Only participants who completed all prior rounds were invited to subsequent rounds. Proposals lacking agreement were refined by the working group, incorporating previous results and common suggestions. The first round included multiple‐choice questions to inform subsequent proposals.
See this image and copyright information in PMC

References

    1. Shah RA, Nwannunu CE, Limmer AL, Patel RR, Mui UN, Tyring SK. Brief update on dermatologic uses of methotrexate. Skin Therapy Lett. 2019;24(6):5–8. - PubMed
    1. Malaviya AN. Landmark papers on the discovery of methotrexate for the treatment of rheumatoid arthritis and other systemic inflammatory rheumatic diseases: a fascinating story. Int J Rheum Dis. 2016;19(9):844–851. - PubMed
    1. SmPC text Methotrexate . 2019. [cited 2024 Apr 8]. Available from: https://www.ema.europa.eu/en/documents/product‐information/jylamvo‐epar‐...
    1. Vermeulen FM, Gerbens LAA, Schmitt J, Deleuran M, Irvine AD, Logan K, et al. The European TREatment of ATopic eczema (TREAT) registry taskforce survey: prescribing practices in Europe for phototherapy and systemic therapy in adult patients with moderate‐to‐severe atopic eczema. Br J Dermatol. 2020;183:1073–1082. - PMC - PubMed
    1. van Huizen AM, Sikkel R, Caron AGM, Menting SP, Spuls PI. Methotrexate dosing regimen for plaque‐type psoriasis: an update of a systematic review. J Dermatolog Treat. 2022;33(8):3104–3118. - PubMed

LinkOut - more resources