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Methotrexate is an antimetabolite having immunomodulatory and anti-inflammatory properties. It has been FDA approved for treatment of severe adult psoriasis and juvenile rheumatoid arthritis for more than 3 decades. Monitoring blood counts and liver function test is recommended, with rare observation of liver function alteration especially in obese due to fatty liver changes. Hence, Methotrexate should be avoided in patients with immunosuppressive conditions, liver disease, obesity, diabetes and alcoholism. Folic acid supplementation help alleviate the gastrointestinal symptoms and anemia.

Methotrexate has the advantage of clearing or improving psoriatic arthritis apart from the cutaneous disease.

Its intramuscular or subcutaneous forms have fewer gastrointestinal adverse effects and require lower dosing as compared to oral tablets.