PA06 Prescribing practices of methotrexate in a general paediatric dermatology department: a two-cycle retrospective audit (2018–2025)

Abstract

Methotrexate is a widely used systemic immunosuppressive agent in paediatric dermatology. It is frequently prescribed as first-line therapy for children and young adults with chronic inflammatory skin conditions. Safe prescribing requires pretreatment counselling, baseline investigations and ongoing monitoring to minimize adverse effects and optimize outcomes. We aimed to evaluate adherence to the BAD guidelines for methotrexate prescribing and monitoring before and after implementing a local clinical guideline and standardized electronic initiation templates in a paediatric dermatology clinic. This two-cycle audit included children and young adults initiated on methotrexate. Cycle one reviewed patients commenced between 2018 and 2022, assessing documentation of counselling, baseline investigations, test doses, initiation dosing, monitoring and adverse events. In 2022, a local guideline and electronic initiation template led by a clinical nurse specialist were implemented. Cycle two data were collected using the same methodology for patients initiated between 2022 and 2025. In total, 57 children and young adults were included (29 male, 28 female; age 3–18 years), with indications including atopic dermatitis (n = 49), psoriasis (n = 7) and alopecia areata (n = 1). Documentation of counselling and baseline assessments improved between cycles. Provision of patient information leaflets increased from 94% in 2018 to 100% in 2025, with improved pregnancy counselling documented for female patients of childbearing age. Recording of baseline disease severity scores (Eczema Area and Severity Index and Psoriasis Area and Severity Index) rose from 14% in 2018 to 86% in 2025. Baseline blood tests were performed in 100% of cases across both cycles. Methotrexate dosing varied (0.19–0.40 mg kg−1) across both cycles; however, test doses, common in cycle one, were discontinued by 2024–2025. Rates of clinical review with a nurse specialist at week 4 improved from 86% in 2018 to 100% by 2025. Implementation of a local guideline with standardized electronic initiation templates led to measurable improvements in methotrexate prescribing and monitoring. Increased use of telephone review for patients with stable disease contributed to improvements in week 4 monitoring.