We agree with the consideration that, regarding the cause of the increase in transaminase levels in the described patient, there are no means of affirming with certainty the association with the MMP® technique.1 We reinforce, however, that she had already shown an elevation of transaminase levels with the previous use of the medication when administered orally. We attributed it to the technique used after excluding other possible causes such as infections, alcohol consumption, physical activity, or use of any other medication, in addition to the transitoriness of transaminitis in relation to the procedure.

The technique involves the penetration of needles into the dermis,2,3 where vascularization is prominent in the scalp, with biological plausibility in affirming the possibility of absorption of the drug used. Additionally the patient is likely to be susceptible to methotrexate-related adverse effects, despite the small, absorbed dose.

We reaffirm the importance of reporting unexpected adverse effects related to the recent use of percutaneous treatment techniques, aiming at patient safety through adequate monitoring.