Background.  Severe plaque psoriasis in childhood has a significant morbidity and can warrant the use of systemic agents, although there are no published clinical trials in this group.

Objectives.  We report a series of 13 children with severe plaque psoriasis treated with low-dose once-weekly methotrexate.

Methods.  We reviewed the notes of all 13 children treated with low-dose methotrexate at Birmingham Children’s Hospital.

Results.  Of the 13 patients reviewed, 11 responded with clearance of psoriasis, leaving small residual plaques. Five patients are currently maintained on methotrexate. Three patients needed two courses of methotrexate and one needed three courses, with treatment-free intervals of between 9 and 22 months. One patient stopped treatment due to rises in the results of liver function tests (LFTs) at 6 weeks, and one patient stopped the second course of methotrexate after two doses because of slightly raised baseline LFT results. There were no other adverse events.

Conclusions.  We propose that when carefully monitored, methotrexate can be a safe and efficacious treatment option for severe psoriasis in children as well as in adults. Obesity may be a relative contraindication, as associated nonalcoholic fatty liver disease is likely to increase hepatotoxicity.