Acitretin, Methotrexate Show Greater Maintenance Versus Cyclosporine in Pediatric Psoriasis

Both acitretin and methotrexate show comparable 2-year drug survival rates among those with pediatric psoriasis, new findings suggest, and these rates are superior to those of cyclosporine.1

Such conclusions resulted from a recent international, multicenter, retrospective cohort study authored by investigators such as Emmanuel Mahé, MD, PhD, from the Service de Dermatologie at the Hôpital Victor Dupouy in France. Mahé et al conducted this analysis to assess the comparative drug survival of cyclosporine, acitretin, and methotrexate in severe cases of psoriasis in children.

They highlighted these medications as commonly implemented by clinicians for years, noting the lack of large-scale comparisons of their efficacy in pediatric psoriasis prior to this analysis.2 This, Mahé and colleagues expressed, had been a limitation.

“[We] evaluated factors associated with the choice of the first systemic treatment, effectiveness, predictive factors for effectiveness, tolerability and reasons for discontinuation or switching treatments.t,” Mahé and coauthors wrote.1

Design and Findings on Drug Survival

The investigators analysis was titled 'ACMe' (Acitretin, Cyclosporine, Methotrexate), and it was designed as an international, multi-center, real-world, retrospective cohort analysis. Their research was carried out across 5 countries, including Italy, France, the United Kingdom, Portugal. and Canada. The team determined which dermatology centers would take part based on their routine use of methotrexate, acitretin, and cyclosporine in treating pediatric patients living with psoriasis.

Participants were eligible if they had been diagnosed with cutaneous psoriasis and were younger than 18 years when they initiated systemic treatments for the first time. In order for them to be included, the patients were required by Mahé et al to have been given acitretin, methotrexate, or cyclosporine as monotherapy, to have taken the drug for at least a single day, and to have had at least 1 follow-up interaction following their initial prescription.

There were 30 dermatology centers across the aforementioned 5 countries which would contribute data. These data were collected via a standardized form for medications administered to pediatric patients in the period between 2014 - 2024. The analysis concluded with 506 inviduals included, corresponding to 683 treatment courses.

Specifically, there were 316 treated with acitretin, 245 with methotrexate, and 122 with cyclosporine. By the 2-year mark, Mahé and colleagues found the median drug survival was comparable for those given acitretin (10.8 months) and those given methotrexate (10.9 months), but significantly shorter for cyclosporine (3.9 months; P < .0001).

Among the leading reasons for discontinuation of treatment, the top examples were shown by the investigative team to be inefficacy for cyclosporine (43.0%) and loss of efficacy for acitretin (27.2%) and methotrexate (31.8%). They did not identify any clinical, demographic, or treatment-related factors as linked to improved persistence of treatment at 6 months.

When acitretin was prescribed as a first-line therapy, drug survival was found to be notably longer (median 11.3 months compared to 5.5 months for second- or later-line use; P < .001). However, the investigators did not identify differences between methotrexate and cyclosporine by line of therapy. Adverse events (AEs) resulted in drug discontinuation among 13.8% of those treated with acitretin, 23.1% of those on methotrexate, and 14.0% of those on cyclosporine (P = .02). A single serious AE, which was determined to be hepatitis, was observed in the methotrexate cohort.

Overall, Mahé and coauthors found acitretin and methotrexate demonstrated similar 2-year drug survival rates, pointing to both outperforming cyclosporine. They did not identify any predictive factors for prolonged duration, except for acitretin’s use as an initial therapy. AEs were a common rationale for patients' choice to discontinue.

“These findings may aid in developing algorithms to formulate recommendations for systemic treatments in managing severe psoriasis in paediatric patients,” Mahé et al concluded.1

References

1. Miao Y, Beauchet A, Yesli Y, et al. Drug survival of systemic treatments for severe paediatric psoriasis: An international retrospective study. J Eur Acad Dermatol Venereol. 2025; 00: 1–15. https://doi.org/10.1111/jdv.70108.

2. Ergun T, Seckin Gencosmanoglu D, Sarioz A, et al. Efficacy, safety and drug survival of conventional agents in pediatric psoriasis: A multicenter, cohort study. J Dermatol. 2017 Jun;44(6):630-634. doi: 10.1111/1346-8138.13713. Epub 2016 Dec 10. PMID: 27943425.