title: Intralesional methotrexate for keratoacanthoma of the nose.
abstract: A 56-year-old woman developed a nodule on her nose. A shave biopsy of the enlarging lesion was performed after 2 weeks and showed a keratoacanthoma. During the subsequent 4 weeks, the lesion continued to grow rapidly, and she was referred for excision of the lesion using the Mohs microscopically controlled technique. A tender 10x12 mm (120 mm2) erythematous nodule with a keratin-filled central umbilication was present on her left nasal ala (Figure 1). Treatment options were discussed. The left nasal ala was locally anesthetized with 1% lidocaine with 1:100,000 epinephrine and the keratoacanthoma was circumferentially infiltrated with 10 mg of methotrexate (0.8 mL of 12.5 mg/mL methotrexate) using a 30-gauge needle. The total amount of methotrexate injected was divided among several injection sites: the peripheral shoulder of the lesion (such that there was blanching of the entire rim) and under the center of the lesion at a depth clinically judged to be the deepest area of involvement. Within the next 7 days, the tumor began to decrease in size and ulcerate centrally. Examination 2 weeks after the initial injection showed a 71% reduction in the area of the tumor, which now measured 35 mm2 (7.0x5.0 mm). The tumor was injected in a similar manner as before with 5 mg of methotrexate. After another 2 weeks, the tumor had continued to shrink. It was flat without nodularity and measured 12 mm2 (4.0x3.0 mm); the tumor area was 66% less than 2 weeks earlier and 90% less than its original size. The residual tumor was again injected with 4.5 mg of methotrexate. There was complete clinical involution of the tumor when the patient returned for evaluation 6 weeks after her initial injection of methotrexate (Figure 2). A biopsy of the lesional area to confirm histologic resolution of the keratoacanthoma was not performed since there was no visible residual tumor. Periodic follow-up examination has been performed and there has been no subsequent recurrence of the keratoacanthoma.
authors.affiliation: Dermatologic Surgery Center of Houston, PA, and the Department of Dermatology, University of Texas-Houston Medical School, Houston, TX 77030, USA.
authors.forename: Philip R
authors.initials: PR
authors.lastname: Cohen
authors.forename: Keith E
authors.initials: KE
authors.lastname: Schulze
authors.forename: Craig F
authors.initials: CF
authors.lastname: Teller
authors.forename: Bruce R
authors.initials: BR
authors.lastname: Nelson
mesh_terms: D000964:Antimetabolites, Antineoplastic / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D015552:Injections, Intralesional; D007636:Keratoacanthoma / Q000188:drug therapy*; D008727:Methotrexate / Q000008:administration & dosage*; D008875:Middle Aged; D009668:Nose Diseases / Q000188:drug therapy*; D016896:Treatment Outcome
chemical_list: D000964:Antimetabolites, Antineoplastic; D008727:Methotrexate