In this video blog, Dr. James Song summarizes his lecture, Methotrexate, Acitrecin, Cyclosporin: Revisiting Old Friends on November 8, 2024, at the 5th Annual Elevate-Derm West Conference at the Westin Kierland Resort in Scottsdale, AZ.

In this video

In conversation with dermatology PA Buchi Nida, Dr. Song calls methotrexate "kind of like the boogeyman" — associated with serious adverse events that are actually "extraordinarily rare" despite how much of it he uses. When side effects do appear, they're usually GI or neurological, and he manages the GI intolerance by starting folic acid at 5 mg on all days except the methotrexate day, adding leucovorin if needed, and switching to the more bioavailable sub-Q form as a last step. He notes that liver biopsies have fallen out of favor thanks to updated AAD guidance, replaced by blood-based tests like the FibroSure that risk-stratify liver health and can be followed annually. He also cites expert consensus that a test dose isn't needed for most patients, and reassures that moderate alcohol use — up to 14 units/week for men, seven for women — doesn't raise liver enzyme elevations.

Turning to cyclosporine, Dr. Song describes it as "a reliable medicine" he now uses less often given biologics and small molecules, but still values for induction while a slower agent like methotrexate kicks in, and as rescue therapy when a patient on a biologic flares. He monitors kidney function closely — rechecking creatinine if it bumps more than 30% over baseline — and asks patients to check blood pressure at home, considering a calcium channel blocker above 140/90. With intermittent and weekend maintenance dosing, he doesn't track the cumulative one-year US limit as strictly.

  • Methotrexate's reputation for serious adverse events is overblown — real-world side effects are usually GI or neurological and "extraordinarily rare."
  • For GI intolerance, start folic acid at 5 mg (not 1 mg) on non-methotrexate days, add leucovorin 6–8 hours after dosing if needed, then switch to the more bioavailable and more effective sub-Q form.
  • Liver biopsies are out; blood-based tests like FibroSure risk-stratify liver health annually — treat cautiously at fibrosis scores of F2–F3 or greater.
  • No test dose is needed for most patients; start at 15 mg/week, check labs at 2–4 weeks, and watch CKD, older, or thrombocytopenic patients more closely. Moderate alcohol (≤14 units/week men, ≤7 women) is acceptable.
  • Cyclosporine remains useful for induction and rescue therapy — monitor creatinine (recheck if >30% over baseline) and home blood pressure, adding a calcium channel blocker above 140/90.