What is methotrexate, and how does it work?
Methotrexate is an older, well-studied medicine, taken as a pill, a liquid, or a weekly injection. It was first developed for cancer, and is used at much lower doses for psoriasis. At those lower doses, it slows the rapid growth of skin cells and calms an overactive immune system. It does not work by killing cells the way high-dose cancer treatment does. It is taken once a week, never daily. Evidence Evidence Evidence
Why this matters
- Sources cited, not yet graded
I read the AAD and National Psoriasis Foundation patient-education pages on methotrexate. Both describe it as slowing skin-cell growth and calming an overactive immune system at psoriasis doses. The 2020 AAD-NPF systemic-therapy guideline lists methotrexate among the established systemic nonbiologic options for psoriasis.
Considerations
- Depends on you
Neither source explains why one person’s skin responds faster than another’s, and neither predicts your own response in advance.
Questions for your dermatologist
Is methotrexate a reasonable option given my psoriasis and what I have already tried?
Saving keeps this on your device and needs JavaScript, which is off in this browser.How is a psoriasis dose different from a cancer dose, and why does that matter for me?
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What does it treat, and where does it fit among other options?
Methotrexate treats psoriasis in the skin. It can also treat psoriatic arthritis, a real difference from topical medicines and phototherapy, neither of which reaches joint disease. It is typically considered for moderate-to-severe psoriasis, either alone or alongside another treatment your dermatologist selects. Evidence Evidence Evidence
Why this matters
- Sources cited, not yet graded
I read AAD patient education, which states that methotrexate can treat psoriasis, psoriatic arthritis, and nail psoriasis. NIAMS patient education describes psoriatic arthritis as needing its own diagnosis and treatment plan, separate from skin-only psoriasis care. The AAD-NPF guideline lists methotrexate among established systemic options for moderate-to-severe disease.
Considerations
- Depends on you
None of these sources says how methotrexate compares with a specific alternative for you, or predicts joint outcomes from skin response.
Questions for your dermatologist
Would methotrexate address both my skin and any joint symptoms, or do I need a separate plan for each?
Saving keeps this on your device and needs JavaScript, which is off in this browser.Would you start with methotrexate alone, or combine it with something else?
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How often do you take it, and how long until you know if it is working?
The current label for methotrexate tablets sets a starting weekly range: 10 to 25 mg by mouth, once a week. Your dermatologist raises that dose gradually, up to a label maximum of 30 mg a week. It is never taken daily - the label itself warns that a mistaken daily dose has caused deaths. Most people notice less psoriasis within four to six weeks. Full clearing can take up to six months. In a 52-week trial of the injected form, 41% of participants reached PASI75, meaning at least 75% clearer skin, by week 16, compared with 10% on placebo. Evidence Evidence Evidence
Why this matters
- Sources cited, not yet graded
I read the current FDA label. It sets the weekly dosing range and states the daily-dosing danger directly. AAD patient education gives the four-to-six-week and up-to-six-month timeline. The trial, 120 adults with moderate-to-severe psoriasis, 91 of them on methotrexate, reports the week-16 PASI75 comparison for the injected form.
Considerations
- Depends on you
The trial studied injected methotrexate, not the tablet form, and is one study population, not a promise for you. The label’s weekly range is a starting framework your dermatologist adjusts; it does not predict how much of that range you personally will need.
Questions for your dermatologist
What weekly dose would you start me on, and how would you adjust it?
Saving keeps this on your device and needs JavaScript, which is off in this browser.When will we check whether this is working for me?
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What are the side effects, and what should make you call your dermatologist?
People I have heard from worry about the liver first, and about how much blood testing this takes. The FDA boxed warning, its strongest warning, covers four areas. Methotrexate can cause fetal death, and it is not safe during pregnancy for non-cancer use. It can trigger severe allergic reactions in people with a prior serious reaction to it. It carries a real risk of serious, sometimes fatal, reactions affecting the bone marrow, digestive tract, liver, lungs, skin, or kidneys, which is why close monitoring is required. And taking it daily by mistake, instead of weekly, has caused deaths. More common effects include nausea, vomiting, appetite loss, mouth sores, and fatigue. Tell your dermatologist about these, since your dose or a folic acid supplement can often be adjusted. Avoid alcohol, since it raises the risk of liver damage. Evidence Evidence Evidence
Why this matters
- Sources cited, not yet graded
I read the boxed warning on the current FDA label. It states the four categories and the once-weekly dosing-error risk directly. AAD and National Psoriasis Foundation patient education both list the common side effects and the value of folic acid supplementation. National Psoriasis Foundation patient education states the blood-monitoring schedule used to catch liver, blood-count, and other problems early.
Considerations
- Depends on you
The label’s own detailed adverse-reaction rate table comes from rheumatoid arthritis trials, not a psoriasis-specific study. Do not read those exact percentages as a psoriasis rate.
Questions for your dermatologist
What symptoms should make me call you right away, versus wait for my next blood test?
Saving keeps this on your device and needs JavaScript, which is off in this browser.How often will I need blood work, and what will you be checking?
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What does it cost?
Methotrexate is an old, generic medicine, and one of the least expensive psoriasis treatments I have written up. A live pharmacy-price snapshot showed an average cash price of about $97 for 24 tablets of the 2.5 mg strength, dropping to about $13 with a common discount coupon. Actual pharmacy prices, insurance coverage, and coupon eligibility vary. Evidence
Why this matters
- Sources cited, not yet graded
I looked at the GoodRx snapshot. It records the dated cash and coupon price for a defined generic prescription.
Considerations
- Depends on you
This is one commercial price-comparison snapshot, not a survey of every pharmacy or insurance plan. It does not include the added cost of required blood monitoring, and it does not state your own plan’s coverage or copay.
Questions for your dermatologist
Does my insurance cover methotrexate, and what would monitoring visits and labs cost me?
Saving keeps this on your device and needs JavaScript, which is off in this browser.Is the tablet or the injected form better covered by my plan?
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What do other people say about using it?
No reader has sent me a first-hand account of methotrexate for psoriasis yet. Until someone does, here is what the label and the studies say about living with it. Evidence
Why this matters
- Sources cited, not yet graded
The once-weekly dosing schedule and the need for regular blood testing. Also documented: the four-to-six-week timeline before most people notice a change.
Considerations
- Depends on you
No one has sent me an account of what the blood-test schedule, or an occasional nausea day, feels like to live with.
Questions for your dermatologist
What have your other patients told you about staying on top of the lab schedule?
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What is worth tracking while you use it?
Keep a dated record of each weekly dose. Methotrexate is dosed once a week, and mistaking it for a daily medicine is dangerous, so a clear log matters. Note your scheduled blood tests and any result your dermatologist flags. Add a same-conditions photo around your four-to-six-week check-in, then again at any later review your dermatologist sets. Evidence Evidence
Why this matters
- Sources cited, not yet graded
A dated, comparable record is what lets the four-to-six-week check-in the AAD and the trial data describe actually answer whether the treatment is working. A clear dose log also supports the once-weekly schedule the label requires.
Considerations
- Depends on you
A dose log and photo record do not replace the required blood testing, and cannot by themselves catch a liver, blood-count, or lung problem.
Questions for your dermatologist
What should I track between now and my first check-in?
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Applicability check
Who was studied?
These fields show what the cited evidence reports about the people and body sites behind outcome or safety claims. “Not reported” means the reviewed source omitted the field; “Pending exact source review” means SteadySkin has not made that determination yet.
People I have heard from worry about the liver first, and about how much blood testing this takes. The FDA boxed warning, its strongest warning, covers four areas. Methotrexate can cause fetal death, and it is not safe during pregnancy for non-cancer use. It can trigger severe allergic reactions in people with a prior serious reaction to it. It carries a real risk of serious, sometimes fatal, reactions affecting the bone marrow, digestive tract, liver, lungs, skin, or kidneys, which is why close monitoring is required. And taking it daily by mistake, instead of weekly, has caused deaths. More common effects include nausea, vomiting, appetite loss, mouth sores, and fatigue. Tell your dermatologist about these, since your dose or a folic acid supplement can often be adjusted. Avoid alcohol, since it raises the risk of liver damage.
- Age range
- Not reported
- Condition subtype
- Not reported
- Severity or extent
- Not reported
- Sample size
- Not reported
- Geography and care setting
- One source is the current US drug label for methotrexate tablets (Trexall). Its adverse-reaction rates come from short rheumatoid arthritis trials, not psoriasis. Two sources are patient education (AAD, National Psoriasis Foundation), describing common reactions and the monitoring schedule in plain language. None reports a trial population with psoriasis.
- Skin tone or phototype
- Not reported
- Race
- Not reported
- Ethnicity
- Not reported
- Body sites
- Not reported
What that means for this page: These sources describe the boxed-warning categories, the weekly-dosing-error risk, common reactions, and the monitoring routine used to catch rarer problems. None states how often a reaction happens in psoriasis care, and none judges one reader’s risk.
Evidence behind this page
Sources
Each evidence badge opens the source and its limits. The full list stays available here.
- American Academy of DermatologyGuideline · Regulatory / guideline, tier 1Relevant relationship disclosed
- Published
- SteadySkin last checked
What this source can and cannot tell you
Why the independence label says this: The guideline reports author relationships; it is not independent comparative proof for an individual choice.
What this source supports
Supports that methotrexate, apremilast, cyclosporine and acitretin are established systemic nonbiologic options considered in psoriasis care.
What it does not support
It does not select, rank or prescribe an option for an individual reader.
Claim-specific review for this source is still in progress. Only the source-level evidence and limits are shown here.
- National Institute of Arthritis and Musculoskeletal and Skin DiseasesPatient education · Patient education, tier 5Independent source
- Published
- SteadySkin last checked
What this source can and cannot tell you
What this source supports
Supports bringing joint, tendon, swelling, stiffness and nail concerns to a clinician because diagnosis uses clinical assessment and may require further evaluation.
What it does not support
It is not an online screening result and cannot diagnose psoriatic arthritis from a checklist.
Claim-specific review for this source is still in progress. Only the source-level evidence and limits are shown here.
- American Academy of DermatologyPatient education · Patient education, tier 5Independent source
- Published
- SteadySkin last checked
What this source can and cannot tell you
What this source supports
Supports that methotrexate works by suppressing the overactive immune system behind psoriasis, and can effectively treat severe psoriasis, psoriatic arthritis, and nail psoriasis. Supports that most people taking methotrexate see less psoriasis in four to six weeks, with full clearing sometimes taking up to six months. Supports that methotrexate is usually taken once a week, never more often without a dermatologist saying so. Supports that it comes as a pill, liquid, or at-home injection, and that it should be supplemented with folic acid. Supports the common side effects of vomiting, nausea, appetite loss, mouth sores, mouth redness and swelling, and fatigue. Supports that these should be reported to a dermatologist right away.
What it does not support
Does not report an exact side-effect rate, does not report a psoriasis-specific clinical-trial population, and does not predict an individual reader’s dose, response, or timeline.
Claim-specific review for this source is still in progress. Only the source-level evidence and limits are shown here.
- National Psoriasis FoundationPatient education · Patient education, tier 5Independence not established
- Published
- SteadySkin last checked
What this source can and cannot tell you
Why the independence label says this: The organization provides patient education, but its editorial and funding independence for this page was not independently reviewed. It is used only for patient-facing treatment-category and monitoring context.
What this source supports
Supports that methotrexate binds to and inhibits an enzyme involved in the rapid growth of skin cells, slowing that growth. Supports that regular blood tests are required to confirm the drug is being safely processed by the liver, white blood cells, and bone marrow. Supports that less common long-term risks include liver damage and reversible liver scarring, a reduced white blood cell count with higher infection risk, and rare lymphoma or bone marrow toxicity. Supports that alcohol should be avoided to reduce liver problems. Supports that men should be off methotrexate at least three months, and women at least four months, before trying to conceive.
What it does not support
Does not report an exact monitoring interval as a single universal schedule, does not report a psoriasis-specific trial population, and does not assess an individual reader’s risk.
Claim-specific review for this source is still in progress. Only the source-level evidence and limits are shown here.
- U.S. National Library of Medicine (DailyMed)Regulatory · Regulatory / guideline, tier 1Independent source
- Published
- SteadySkin last checked
What this source can and cannot tell you
What this source supports
Supports the boxed warning, the label’s strongest warning, in four parts. It covers embryo-fetal toxicity, including fetal death; the drug is contraindicated in pregnancy for non-cancer use. It covers contraindication after a prior severe hypersensitivity reaction. It covers serious, sometimes fatal, reactions affecting the bone marrow, GI tract, liver, lungs, skin, and kidneys, which is why close monitoring is required. It covers death reported when tablets were taken daily by mistake instead of weekly. Supports the labeled psoriasis dosage of 10 to 25 mg orally once weekly, raised gradually to a maximum of 30 mg weekly, with folic or folinic acid supplementation recommended. Supports contraception during treatment and for 6 months after the final dose for females of reproductive potential, and 3 months after the final dose for males. Supports an adverse-reaction table from 12-18 week rheumatoid arthritis studies. At 10% or greater: elevated liver tests (15%) and nausea or vomiting (10%). In the 3%-10% range: stomatitis and low platelet count. In the 1%-3% range: rash, diarrhea, hair loss, and low blood-cell counts.
What it does not support
The adverse-reaction rate table comes from rheumatoid arthritis trials, not a study of people with psoriasis, and does not state how often any reaction occurs in psoriasis treatment. Does not predict an individual reader’s dose or response.
Claim-specific review for this source is still in progress. Only the source-level evidence and limits are shown here.
- The Lancet (Warren RB, et al.)Randomized trial · Clinical research, tier 2Independent source
- Published
- SteadySkin last checked
What this source can and cannot tell you
What this source supports
Supports a randomised, double-blind, placebo-controlled phase 3 trial of subcutaneous (injected) methotrexate in 120 methotrexate-naive adults with moderate-to-severe plaque psoriasis. It ran at 16 sites in Germany, France, the Netherlands, and the UK, with 91 participants on methotrexate and 29 on placebo. Supports a PASI75 response in 37 of 91 (41%) methotrexate participants versus 3 of 29 (10%) placebo participants at week 16. Supports that subcutaneous methotrexate was generally well tolerated over the full 52-week treatment period, with no deaths, serious infections, malignancies, or major adverse cardiovascular events. Supports serious adverse events in 3% of methotrexate participants.
What it does not support
This trial studied the injected form, not the oral tablet form, and is one study population, not a guarantee of a given response for an individual reader. Does not report outcomes for methotrexate combined with another treatment.
Claim-specific review for this source is still in progress. Only the source-level evidence and limits are shown here.
- GoodRxPatient education · Patient education, tier 5Relevant relationship disclosed
- Published
- SteadySkin last checked
What this source can and cannot tell you
Why the independence label says this: GoodRx is a commercial pharmacy-price and coupon marketplace. Displayed prices can vary by prescription, pharmacy, location, and time.
What this source supports
Supports only the dated retail-cash and coupon-discount price recorded for 24 tablets of generic methotrexate 2.5 mg: an average retail cash price of $97.15, and an average GoodRx-coupon price of $12.70.
What it does not support
It does not guarantee availability, coverage, coupon eligibility, or a personal price.
Claim-specific review for this source is still in progress. Only the source-level evidence and limits are shown here.