Psoriasis treatment: Methotrexate

Methotrexate is a strong medicine. The US Food and Drug Administration (FDA) approved it to treat adults with severe, disabling psoriasis that cannot be controlled with medicine applied to the skin or light treatments. Methotrexate works by suppressing the overactive immune system that causes psoriasis.

Why do dermatologists prescribe methotrexate to treat psoriasis?

This prescription medicine can treat:

• Severe and disabling psoriasis

• Erythrodermic psoriasis

• Psoriatic arthritis

• Nail psoriasis

• Palmoplantar psoriasis

Avoid alcohol

Your dermatologist may tell you to stop drinking alcohol while taking methotrexate. This can reduce problems with your liver.

Safety and effectiveness

Methotrexate can effectively treat severe psoriasis, psoriatic arthritis, and nail psoriasis. Most patients see less psoriasis in four to six weeks. It may take six months to get complete clearing. While it can be very effective, no treatment works for everyone. For some people, adding another treatment can deliver the best possible results. Before you can take methotrexate, your dermatologist will carefully evaluate you to decide if you can take it. Be sure to tell your dermatologist about:

• All medicines that you are taking, including ones that you can buy without a prescription such as ibuprofen (Advil, Motrin) and naproxen (Aleve)

• Diseases that you have and ones that run in your family

• How much alcohol you drink

• If you are pregnant or want to become pregnant

Pregnancy: Women who are pregnant or planning to become pregnant should NOT take methotrexate. This medicine can cause miscarriages and serious birth defects. 

Stop methotrexate before getting pregnant

Want to have a child? Both men and women who take methotrexate should stop taking this medicine and wait at least 3 months before trying to have a child.

Breastfeeding: Women who are breastfeeding should NOT take methotrexate.  Children: Methotrexate is FDA-approved to treat adults with severe psoriasis. The FDA has also approved it to treat children with juvenile rheumatoid arthritis, so we know a bit about how this medicine works in children.  In general, children tend to do well on this medicine and have fewer side effects.  Children take methotrexate for the shortest possible time, and dermatologists tend to prescribe the lowest possible dose.  To get the best possible results while treating psoriasis, a dermatologist may add another treatment to a child’s treatment plan.  If your dermatologist says that methotrexate may be a medicine you can take, you’ll need to have some medical tests first, such as blood work. You’ll also need a tuberculosis (TB) test.   While taking methotrexate, you’ll need blood tests to see if the medicine is affecting your liver. 

Methotrexate and the sun

When taking methotrexate, you should:

• Protect your skin from sunlight

• NOT use sunlamps or tanning beds.

Sun protection will help prevent sunburn and psoriasis flares.

How to take methotrexate

Methotrexate comes in many forms. You may be prescribed a pill or liquid. Some patients inject methotrexate at home. Each form has benefits. For example, injecting methotrexate can reduce side effects such as nausea and vomiting. 

Before taking methotrexate for the first time, be sure to carefully read the instructions. If the instructions are confusing or differ from what your dermatologist said, call your dermatologist before taking methotrexate.  Some patients stay on methotrexate for a long time. Others stop taking methotrexate once their psoriasis is under control and restart when psoriasis flares. 

Follow recommended dosage

Most people take methotrexate once a week. Taking it more often than your dermatologist prescribes can cause serious health problems.

Possible side effects

Methotrexate can cause many possible side effects, so dermatologists carefully monitor each patient. Vomiting, nausea, loss of appetite, mouth sores, redness and swelling inside the mouth, and fatigue are common side effects. If you experience any of these side effects, tell your dermatologist immediately. Your dermatologist may be able to control these side effects by changing how you take methotrexate or adding a folic acid (a type of B vitamin) supplement to your treatment plan.  More-serious side effects are also possible. Methotrexate can reduce your body’s ability to fight infections. It can also have serious effects on your liver, lungs, or kidneys. When found early, these side effects can often be stopped, so it’s important to:

• Immediately tell your dermatologist about any side effects

• Get all of the medical tests that your dermatologist requires

To check for liver problems and other side effects, you will need to have blood tests. When you start taking methotrexate, you may need to get a blood test every two to four weeks for a few months. Then, you’ll likely need a blood test every one to three months. If a test result shows a problem, you may need to stop taking methotrexate. 

What to discuss with your dermatologist

Be sure to tell your dermatologist if you:

• Experience any health problem, even if it seems unrelated to taking methotrexate, such as fever, chills, body aches, bleeding, or bruising easily

• Become pregnant

• Feel uncertain about how to (or how often to) take methotrexate

• Think the information that came with the medicine about how to take methotrexate differs from what your dermatologist told you

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References
Cordoro KM. “Management of childhood psoriasis.” Adv Dermatol. 2008;24:125-69.

Feldman SR. “Treatment of psoriasis.” UpToDate 2015 Jul, Wolters Kluwer Health. Last accessed November 2015. 

Hugh J, Van Voorhees AS, et al. “From the Medical Board of the National Psoriasis Foundation: The risk of cardiovascular disease in individuals with psoriasis and the potential impact of current therapies.” J Am Acad Dermatol. 2014;70:168-77.

Marks, B. “More than skin deep: Triggers, treatments, and you.” An educational session hosted by the National Psoriasis Foundation. Chicago: Presented June 20, 2015.

Menter A, Korman NJ, et al. “Guidelines of care for the management of psoriasis and psoriatic arthritis Section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents.” J Am Acad Dermatol2009;61:451-85.