When discontinuing methotrexate (MTX) for eczema, should it be tapered down or stopped entirely?

Discontinuing Methotrexate for Eczema: Taper vs. Abrupt Cessation

Methotrexate can be discontinued abruptly without adverse effects when treating eczema, though tapering may reduce the risk of disease flare and is preferred when feasible. 1

Evidence for Abrupt Discontinuation

The most recent pediatric consensus guidelines (2024) explicitly state that MTX can be discontinued abruptly without adverse effects, other than risk of disease worsening 1. This represents expert consensus from dermatology specialists specifically addressing inflammatory skin disease, including atopic dermatitis.

However, this recommendation must be balanced against practical considerations:

• The rate of taper should be based on disease severity, risk of disease worsening, and patient/caregiver preference 1
• Abrupt discontinuation carries a 30-50% relapse rate within 12 months in rheumatologic conditions 2, 3
• In the landmark 2007 prospective trial, 8 of 9 patients maintained improvement 12 weeks after stopping MTX, with mean disease activity remaining 34% below baseline 4

Recommended Tapering Approach (When Chosen)

If you opt to taper rather than stop abruptly, the American Academy of Dermatology guidelines recommend:

• Taper slowly over 2-3 months rather than abrupt discontinuation to minimize flare risk 3
• Once clearance or near-clearance is achieved and maintained, MTX should be tapered or discontinued 1
• Reduce the weekly dose by half initially, then further reduce by 2.5 mg increments every 4-8 weeks if disease remains controlled 3
• Alternatively, extend the dosing interval to every 2 weeks while maintaining the same dose 2, 3

Clinical Decision Algorithm

For patients with mild-moderate eczema or short treatment duration (<6 months):

• Abrupt discontinuation is reasonable 1
• Maintain topical therapy and emollients 1

For patients with severe eczema, prolonged treatment (>12 months), or history of rapid flares:

• Taper over 2-3 months 3
• Schedule follow-up visits every 4-8 weeks during tapering 3
• Monitor for disease recurrence at each visit 3

If disease flares during or after discontinuation:

• Restart MTX at the previously effective dose immediately 2
• Consider maintaining low-dose therapy (5-7.5 mg weekly) rather than complete discontinuation in severe cases 2, 3

Important Caveats

• Non-responding patients on adequate doses (≥15 mg/week) should discontinue after a 12-16 week trial 1
• The majority of improvement occurs by week 12; patients not responding by this point despite dose escalation are unlikely to benefit from continued therapy 1, 4
• Laboratory monitoring can be discontinued once MTX is stopped, though one final CBC and liver function test 4 weeks post-discontinuation is prudent 1
• Unlike some immunosuppressants (particularly efalizumab in psoriasis), MTX discontinuation does not typically cause rebound worsening beyond return to baseline disease activity 1