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Superficial Tissue Necrosis Related to Methotrexate Injection in a Patient With Rheumatoid Arthritis.

M ethotrexate (MTX) is the frontline treatment for rheumatoid arthritis. Common mucocutaneous adverse events, such as stomatitis, are recognized. Nonfrequently, papular eruptions may occur as expression of small vessel vasculitis. Skin ulcers with subcutaneous injection of MTX are described as a rare adverse event in patients with psoriasis, either on psoriatic plaques or on normal skin. Proposed triggers are accidental overdose or introduction of an interacting agent. Cutaneous toxicity is usually dose related and can occur when recommended guidelines are ignored. The present case reports an adverse event associated with an error in administration. Early diagnosis and appropriate multidisciplinary treatment led to a favorable outcome. A 53-year-oldman with a medical history of anxiety disorder and smoking had a diagnosis of early seropositive rheumatoid arthritis. Step-up therapy with MTX was used owing to moderatehigh disease activity based on DAS 28 index. A month after switching to parenteral administration (20 mg aweek) and adding leflunomide, he consulted owing to the appearance of 2 necrotic lesions in the rectus abdominis area, where he had administered the drug too superficially, he recalls, although he and his wife were both previously trained and stored the drug properly. Initially, the necrotizing superficial lesions of the abdominal wall, involved skin, and a surface portion of the subcutaneous fatty tissue (A). Results of bacterial cultures were negative.