Methotrexate, psoriasis and nosebleeds
A good friend of mine – let’s call him Paul – was recently admitted to hospital with a severe nose- bleed (epistaxis). It had started early in the day, but by evening showed no signs of stopping, so he and his wife went to the local A&E. Following his admission, he was quickly taken in for treatment and observation. After packing and cauterisation, the bleeding eventually stopped, and he was discharged with an appointment to see an ENT consultant surgeon. It seems the bleeding stemmed from a perforated nasal septum (the cartilaginous structure between the nostrils), which may require surgical correction.
Paul has a number of health problems, including rheumatoid arthritis and whilst he was in hospital, it seems he was told this can sometimes be associated with septal perforation and – hence - nosebleeds. I had never heard of this and, given that psoriasis, like rheumatoid arthritis, is a chronic, autoimmune, inflammatory disorder, it occurred to me that nasal septal perforation (NSP) and nosebleeds, may be more common in individuals with psoriasis.
The only evidence of any association between psoriasis and NSP, seems to come from a very small study published in 1976, which reported on NSP in 12 patients, with a mixture of rheumatic disorders, only 2 of which had psoriatic arthritis1. Interestingly, biopsies taken from 7 of these patients, revealed no abnormalities. The authors concluded that NSP is an occasional finding in rheumatic diseases, but the cause is unknown. So, the most we can say is that with regard to psoriasis, NSP – and hence nosebleeds - may occur occasionally, but we don’t know how often. However, given that nosebleeds are common in the general population and are usually due to perfectly benign causes, we can say that there is unlikely to be any significant association between psoriasis, NSP or nosebleeds.
Interestingly, however, whilst nosebleeds may not be a direct result of psoriasis itself, there is evidence that a drug used in the treatment of psoriasis – methotrexate – can cause NSP and nosebleeds. A small study from the UK in 2021, reported on three patients taking methotrexate for rheumatoid arthritis, in whom various signs of toxicity – including NSP – were noted2. Another study, this time involving two children, aged 8 and 11-years respectively, also reported NSP in the setting of methotrexate therapy3. Other studies have shown similar associations between methotrexate and NSP4,5.
The mechanism involved is likely to be due to impaired regeneration/repair of the nasal lining - epithelium – which would have the effect of thinning the tissue of the septum, predisposing it to perforation.
Conclusion
Whilst probably uncommon, nasal septal perforation and nosebleeds, may be a side-effect of methotrexate treatment in patients with psoriasis.
Interestingly, neither NHS websites nor MedlinePlus, specifically mention this complication. Both doctors and patients need to be aware of the potential for nasal perforation and nosebleeds in those on long-term methotrexate treatment.
References
- Willkens RF, Roth GJ. Novak A et al. Perforation of nasal septum in rheumatic diseases. Arthritis Rheum,1976; 19: 119-21
- Shah A, August S, Jain S and Morgan C. BI22: A three‐patient case series: methotrexate‐induced nasal septal perforation, mucositis, and widespread ulceration. British Association of Dermatologists, 2021: 185 (Suppl. 1), pp142–156
- Lee, Scott L., et al. Potential predisposition for nasal septal perforation with methotrexate use: report of 2 cases and literature review. Ear, Nose and Throat Journal, 2009; 88(8):E12-4
- Meyersburg, D.; Roedel, R. M. W et al. Nasal septum perforation under long-term therapy with low-dose methotrexate in a patient with psoriasis and psoriatic arthritis. 2011: JDDG Journal der Deutschen Dermatologischen Gesellschaft, 9 Malden: Wiley-blackwell.
- Kaminska EN, Sansaricq F, Petronic-Rosic V. Methotrexate-Induced Nasal Septal Perforation. Skinmed. 2016; 14:139-40.
Author:
Dr W D Ashton. MD PhD