Comparing the effectiveness and drug persistence of methotrexate, cyclosporine, and acitretin for psoriasis.

Background: Conventional systemic agents remain the cornerstone treatment for psoriasis because of their availability and cost-effectiveness. However, few studies have compared the effectiveness and drug persistence of these agents in Asian populations. Objectives: To evaluate the effectiveness and drug persistence of methotrexate, cyclosporine, and acitretin, and to identify factors associated with these outcomes. Methods: We reviewed data from 338 psoriasis patients treated with methotrexate, cyclosporine, or acitretin. Results: Out of 473 treatment courses, 239 (50.5%) involved methotrexate, 123 (26%) involved acitretin, and 111 (23.5%) involved cyclosporine. After 1 year, the proportion of patients who achieved absolute Psoriasis Area and Severity Index (PASI) ≤ 2 was greater with methotrexate (30.6%) and cyclosporine (22.2%) than with acitretin (9.5%). For absolute PASI ≤ 4, methotrexate (57%) and cyclosporine (47.2%) showed greater effectiveness than did acitretin (34.9%), with a significant difference only between methotrexate and acitretin (P = .017). The effectiveness findings were consistent in both the 1- and 3-year analyses. Multivariate analysis revealed that a high baseline PASI score significantly reduced the effectiveness of both methotrexate and cyclosporine. For methotrexate, a high body mass index was also associated with reduced effectiveness, whereas for acitretin, scalp involvement and male sex were key factors. Methotrexate demonstrated the longest drug survival at 1 year. Higher ages at psoriasis onset and systemic treatment-naive status were correlated with longer drug survival. Conversely, a higher body mass index and psychiatric comorbidities were linked to shorter survival. Limitations: Methotrexate is typically the first-line systemic therapy in Thailand, which may underestimate the true efficacy of cyclosporine and acitretin when used subsequently. Conclusion: Methotrexate was more effective and persistent than were cyclosporine and acitretin in a real-world setting.