Many members of MyPsoriasisTeam have used methotrexate for the treatment of psoriasis. One member said they were taking methotrexate for years until it wasn’t as effective. “The psoriasis calmed down, and my body didn’t hurt” while they were on methotrexate, they stated.

Methotrexate is a medication that has been used to treat psoriasis and psoriatic arthritis since 1972. Given in either oral form or by injection, it is used to suppress the immune system and slow down cell turnover, both of which are involved in the development of psoriasis. Reducing these symptoms can help improve the quality of life for people living with psoriasis.

To better understand the use of methotrexate in psoriasis treatment, MyPsoriasisTeam spoke with Dr. Alexa Kimball. Dr. Kimball is a professor of dermatology at Harvard University and is also CEO and president of Harvard Medical Faculty Physicians, Beth Israel Medical Center.

What Is Methotrexate, and How Does It Work?

A medication in the class of antimetabolites, methotrexate works by blocking a cell’s ability to continue to replicate (make copies of itself). In psoriasis, an overactive immune system allows skin cells to have an abnormally fast growth cycle, which results in the symptoms of painful scales and plaques on the skin. Methotrexate reduces inflammation and decreases the excessive growth of skin cells.

Methotrexate is also used to treat rheumatoid arthritis and some types of cancer, although in those cases, it’s usually given in much higher doses than it would be when treating psoriasis.

How Do You Take Methotrexate?

Methotrexate can be given orally in pill or liquid form, by subcutaneous injection (under the skin), or through intravenous infusion (into a vein). For psoriasis treatment, methotrexate is most often prescribed by dermatologists in pill form or as an injection, usually given once a week. When a person is taking methotrexate, folic acid levels in their body may be depleted, and a folic acid supplement is often recommended.

Who Should Take Methotrexate?

Initial therapy for psoriasis often involves a topical (applied to the skin) cream or ointment, such as a steroid cream. When topical therapy is no longer effective or does not provide adequate improvement in symptoms, systemic therapy is used. Systemic therapy treats the condition throughout the entire body. Methotrexate is a systemic therapy that can be used for moderate to severe psoriasis. This medication is less commonly used now that biologics are available. Clinical trials have shown that although methotrexate works better than a placebo, it’s not as effective as biologic therapy.

“I definitely do use methotrexate,” Dr. Kimball said. “But, I certainly use it less for psoriasis than I used to.” Methotrexate has a success rate of 25 percent to 30 percent as compared to biologics, which have a success rate of 80 percent to 85 percent, she explained.

Dr. Kimball finds that the group in which she uses methotrexate most often includes people on the borderline of having too much disease for topical treatments but not so much disease as to require biologics. “We also sometimes use it in combination with biologics because of its effectiveness,” she noted.

How Long Does Methotrexate Take To Work?

Many MyPsoriasisTeam members wonder how fast methotrexate works after you’ve started taking it. After just a few weeks of therapy, many people taking methotrexate noted an improvement in psoriasis symptoms, with maximum improvement typically observed after about two to three months of therapy.

One MyPsoriasisTeam member started to notice an improvement in symptoms three weeks after starting and is hoping for more. Another said that after a “severe acute psoriasis rebound, I took methotrexate 10 mg for three weeks. Now, I’m feeling better.”

Your psoriasis won’t improve from methotrexate right away — patience is key to successful treatment. If you are thinking about stopping methotrexate for psoriasis because you aren’t seeing results, talk to your doctor about your concerns.

Benefits of Methotrexate

Some of the benefits of methotrexate compared to other drugs include the cost and amount of time between doses.

Estimated Cost

One of the benefits of using methotrexate to treat psoriasis is that methotrexate is inexpensive, especially compared to biologic therapy. The yearly cost of biologics can be tens of thousands of dollars compared to approximately $1,200 for methotrexate. The yearly cost for the individual being treated with methotrexate or another treatment will vary based on their health insurance. Dr. Kimball stated that in her experience, “sometimes, insurers will ask you to try [methotrexate] first” before authorizing the use of an expensive biologic medication.

Some MyPsoriasisTeam members have had to try methotrexate before their insurance companies would consider authorizing a biologic. One member commented, “I am just checking a box for the insurance company” while hoping for relief of symptoms.

Convenient Dosing

Convenient dosing is also a benefit, as methotrexate generally only needs to be taken once weekly, and typically in pill form instead of injection or intravenous infusion. You can take oral methotrexate at home without discomfort and don’t need to travel to an infusion center. If methotrexate needs to be given by injection, people usually give themselves the injection at home.

Drawbacks of Methotrexate

Like all medications, methotrexate has drawbacks, including comparative effectiveness, side effects, and medical reasons that may exclude you from taking it.

Effectiveness

One drawback to using methotrexate is that it is not as effective in treating psoriasis as biologic therapy, as Dr. Kimball explained. Clinical trials have shown methotrexate to have a better treatment response over placebo, but reduced effectiveness when compared to biologic therapy.

Toxicity

Methotrexate, when used over time, may cause accumulating toxicity, particularly liver disease. Although uncommon, taking methotrexate can increase the risk of developing some serious side effects, such as lymphoma, melanoma, and lung cancer.

Required Supplementation

Another drawback is that when taking methotrexate, you’ll usually need to take folic acid supplements. Often, people with psoriasis may take other medications as well, and adding more pills can feel overwhelming.

Health Conditions

If you have certain health conditions, methotrexate should not be used. This group includes:

• People with a history of liver disease
• Those with low counts of white blood cells, red blood cells (anemia), or platelets prior to starting therapy
• People who are pregnant or nursing

Side Effects of Methotrexate

Low-dose methotrexate given for psoriasis has the potential for side effects, but is generally well tolerated. However, some people experience side effects that make methotrexate hard to continue. “I have been taking it for nine years without too much trouble, but just recently, it has become increasingly difficult to tolerate,” one member said. The most common adverse events include:

• Fatigue
• Nausea and vomiting
• Diarrhea
• Headaches
• Bone marrow suppression resulting in low white blood cells, anemia, or low platelets
• Mild hair loss

Nausea, vomiting, and diarrhea side effects can sometimes be relieved by splitting the methotrexate dose into three divided doses given every 12 hours each week. Some side effects, such as kidney and liver dysfunction, have been found with long-term use of methotrexate. These risks can be higher in those with other underlying medical conditions, such as obesity or diabetes, or if taking other medications that affect kidney and liver function. Frequent alcohol use while taking methotrexate can increase the risk of liver damage. Routine blood tests of kidney and liver function are typically performed to assess these potential side effects. If the side effects of methotrexate are harming your health, it may be time for you and your doctor to consider other treatment options.

Talk With Others Who Understand

MyPsoriasisTeam is the social network for people with psoriasis and psoriatic arthritis and their loved ones. On MyPsoriasisTeam, more than 124,000 members come together to ask questions, give advice, and share their stories with others who understand life with psoriasis and psoriatic arthritis.

Are you living with psoriasis and have been treated with methotrexate? Share your experience in the comments below, or start a conversation by posting on your Activities page.