Sun Rash maybe from Methotrexate?

[janson]

Has anyone here suddenly developed a rash from sun exposure after having been on Mtx for a little over a year?

After a day or so out in the garden (summer has hit full swing in these parts at last ) I have developed a rash (raised bumps, sometimes a little itchy) on the tops of my ears, the back of my hands and forearms, and the back of my neck (sun exposed areas, except my face). It’s been hanging around for about 5 days now, and is annoying (not mention rather unsightly).

Am wondering if it might be a side effect of the Mtx and if anyone else has had experience with this sort of thing?

[Sybil]

Please, wot is ‘sun’??

Okay, I remember now. As far as I know a reaction to sun is fairly common when taking Mtx. It doesn’t get me that way so I’m not well-informed but my impression is that it’s nothing to worry about and should go away soon. I think you’ll be needing to cover up in future, not sure if sunscreen works, I think so.

[janson]

Haha, yep, when it first turned up here I thought that big yellow glowing thing in the sky must have been some sort of UFO we’d had such a long wet spell, then bam, sudden jump into warm/hot dry weather, it was great to spend some time outside getting some of the many overdue chores done around the place

Not too worried, as such, about the rash, it doesn’t look too pretty though (not that I worry much about appearances either lol)… am more curious about how common it is, it’s the first time I’ve ever had anything like this… also wondering if it might be seen as failing Mtx, and maybe a need to try something different by way of meds. Have a rheumy appt on Friday, so will be interesting to see what he has to say about it, if it’s still visible by then

[Sybil]

I’ll keep going while we wait for others who have actually had this! I think it is pretty common and that it’s very unlikely to constitute an Mtx fail. I’d put money on both if I were a betting woman.

[janson]

Oh cool!!! That’s really good to hear, thanks Sybil!! Although the Mtx isn’t being as effective as I would like, until this I was getting off pretty lightly with SE’s from it (the only notable one now being regular oral thrush) and don’t really want to throw it away yet as from what I understand it can be beneficial when biologics are thrown in the mix. Besides it does seem to have helped relieve the fatigue a little, and I’ve lost about 8kgs on it too, which has to be a very good thing

[janson]

OK, neither the rheumy nor his registrar, I saw them both today, think this rash is from the Mtx… I did wonder, as it would seem the sun rash from Mtx is more like a severe and very rapid sunburn (from what I read anyways)… so it’s a wait and see what happens and if the rash doesn’t settle it’ll be off to a dermatologist to have it looked at… I also have noticed the joints are a little worse too (since this rash came up)… so it would seem the Mtx is not having the desired impact, so we are now adding leflunomide to the mix, as a second DMARD… if that fails then I might get a look at one of the biologics. Here’s hoping the leflunomide helps some

[Sybil]

So the plot thickens! Typical flaming PsA!

Last time I had a psoriasis flare nobody could diagnose what the heck it was though I was pretty sure most of it was psoriasis & that was the eventual dx. I had one bit biopsied as it looked like skin cancer apparently - the result came back as ‘partially treated psoriasis’. So an ‘atypical’ psoriasis due to Mtx could be one of the many possible explanations.

Very good luck with the dual treatment. You don’t grow grapes do you? Lef is even more of a no-no with alcohol than Mtx is. So biologics got a mention … promising!

[janson]

Hahaha… yep on the typical PsA… ermmm… or maybe not… there was a wee discussion about possibly lupus rash, has spared my face though, and previous ANA have been variable and very low positives so unconvincing at this point.

Hmm… I’d be surprised if this is psoriasis, although won’t rule anything out at this point. Of all the skin rash photos I’ve looked at over the last week or so the nearest things I have found to how this looks would be either Polymorphic Light Eruption or Lupus, from what I read it is not uncommon for lupus to initially present as PLE or be misdiagnosed as such… what’s really funny about that is when I was ill for a couple of years back around 2007-08 I developed a “malar” type rash on my face… a hallmark of Lupus, but that was kinda dismissed because of such low positives in tests.

The rheumy’s first instinct when he saw this today was perhaps some kind of “little critters” I think if that were the case it would probably not be so prevalent in sun areas (there is only a small patch of about 4 little spots in any area that was covered from the sun) but would have spread more to other areas of the body. Anyways, both the rheumy and his registrar (who is lovely and I genuinely felt took me seriously today) seem to be a bit flumoxed with the rash, so it’s a watch and see as far as that goes.

However, the rheumy did find a ropey tendon in my hand today and says that it’s a type of tenosynovitis that “only” comes from inflammatory arthritis, usually RA, so at least now they have actually found something that really does fit lol.

I’m not a drinker so the no alcohol thing wont worry me in the least… now if they said no tea or cigarettes I’d be completely horrified haha Nah, I don’t grow grapes

It was me that raised the issue of the biologics… but the same rules apply here as most places… need fail two DMARDS, and I can’t take sulfa based meds so leflunomide was the next on the list… my biggest concern with the leflonomide I think will be blood pressure, mines already pretty high and not staying down despite quinapril and a beta blocker… so we’ll take extra care of checks on that for the next few weeks, and bloods will be done every 2 weeks to start with… and today I was given the phone number of the rheumatology nurse at the hospital to call if I have concerns about reactions to leflunomide or flare of symptoms, she will check it out with the rheumys and let me know what to do about it… that’s pretty reassuring as to date I’ve kinda felt like I was flying out here mostly solo between rheumy appts… My GP is pretty popular and it’s usually a 2 week wait to get to see him lol

Anyway, I actually feel like today was the most positive rheumy appt I’ve had to date, with some movement forward on the meds, and the registrar seems keen to follow through and get rolling with treatment… here’s hoping it’s onwards and upwards from here… it has seemed like such a long wait to get this far.

[janson]

Here’s some pics of that rash on back of wrists, back of left hand and back of neck… sorry about the quality of the pics took them quickly on my little cheapy phone a couple of days ago… a bit tricky to get a pic of the back of your own neck haha… they don’t really show quite how bright pink the spots get at times… as the rheumys seem a bit flummoxed by it, I thought I share the pics to see if anyone out there has had this type of rash on sun exposed areas from either meds or Psoriasis?

[Poo_therapy]

Ahh you smoke. I get a skin rash from the sun because I’m addicted to nicotine. I used to smoke and the rash was much worse, now I vape but still use nicotine and the rash although less still appears.

In the 1960’s my mother was on holiday in the South of France and she developed a rash. The French doctor told her it was because she smoked. When she gave up decades later, the rash also disappeared. I smoked from about the age of 13 and developed this rash in my 20’s.

My mother and I found the only thing to stop the rash appearing was factor 50 sunscreen and not sun bathing. Just seen your photos and it looks similar. It can be intensely itchy and sore?

[janson]

Ahh OK… could be right… I’ve been a smoker for 41 years and this is the first time I’ve ever had anything like this come up (except for in feb this year I got a tiny spot on the back of my right wrist, after having been working outside in the garden, it looked similar to this, a GP I saw for something else said it was definitely an inflammatory rash… it disappeared after a couple of weeks)… definitely something to consider

Oh and yes it does get a little itchy but only for a few minutes here and there, nothing that’s really a bother.

[janson]

And forgot to mention that most of the pink goes out of it when away from sun or UV lighting inside (I have UV free LED lighting in the areas I spend most time in my house)

[Jen75]

Yes, most of the time my very mild psoriasis turns up as bright pink, slightly raised, somewhat sensitive spots on my elbows. They look just like your photos.

Whist I can’t really tell about you from your photos, there are two reasons I’m relatively sure mine is psoriasis;

My Sister gets very significant psoriasis, and usually the plaque stage is preceded by these pink spots;
Very occasionally when I get a flare (my psoriasis is usually non-existent), my pink spots transform into classical psoriasis plaques - but this has only happened around twice in 6 years - mostly they just stay as pink spots.

Having said all that, if you have other indicators of lupus, great idea to keep an eye on it

[janson]

Thanks @Jen75… it may well prove to be something in the psoriasis line… the psoriasis I’ve had to date has always been very mild… typical plaque on elbows, and inverse in belly crease (I’d say that’d probably hit the moderate rating), and I do have very minor nail pitting too… infact the elbow rash I didn’t put down to psoriasis, I had just been calling it my “crusty elbow” haha… In my early 30’s when I was first diagnosed with psoriasis I had tiny little spots on my fingers that were intensely itchy, the dermatologist said defo psoriasis, and have had minor bouts of that again in the last couple of years. These spots look a bit like a blister, but don’t have fluid, it’s more like solid flesh that stands up about 1mm when at their worst… a little itchy every now and then, but not intensely or consistently so… seemed interesting to me that joint issues should worsen around the time this came up too… but might just be coincidence.

To be honest I thought when a rheumy looked at it it would be an instant “ahh… yes… that’s from xxx” type of reaction, so was a little surprised when that’s not how it went lol

[Sybil]

Like Jen, if I had that I’d think psoriasis, some of mine’s like that. I do quite a range … very little these days but during that flare up I mentioned, 6 different diagnoses were considered, including discoid lupus. Not saying that yours is psoriasis, but probably best not to exclude it.

[janson]

Cool!! Thanks again @Sybil, yep, you guys may very well be right and I’m not ruling anything out this point… probably shouldn’t have expected rheumys to know what it was, I know they are not dermatologists, but assumed they would have probably seen it before given that they must have seen a considerable number of PsA patients lol

@Poo_therapy… the smoking thing might have some merit too as smoking seems to be one of the possible contributing factors to both psoriasis and PsA… perhaps there is a connection there… I do have an e-cig here, and found it quite good for reducing ciggie count for a little while… but still seem to need those ordinary ciggies too… there’s no arguing that I’m a definite nicotine addict, of the worst kind

[janson]

Sorry everyone, I only just realised I hadn’t followed through on this topic, will do so now.

That rash took about 3 weeks to settle down to almost not visible. I stayed well out of the sun during the middle of the day, but did expose those patches to sun during early morning and late afternoon times.

There are still a few little spots that are almost visible, and do pink up a bit when out in stronger sun, but don’t come to anything and lose their colour pretty quickly once I get myself out of the sun.

I guess now it will be “wait and see” till the start of next summer to see if it returns or if it was just a one off thing.

Thanks everyone for your support and comments on this topic!! Most appreciated!!!