Eczema
Treats mild to moderate flares.
Elidel vs Methotrexate
Elidel: A steroid-free anti-inflammatory cream for eczema. It calms the immune reaction in the skin without thinning it, which is why it is used on the face, eyelids and skin folds. Methotrexate: An old, inexpensive tablet or injection for severe psoriasis and psoriatic arthritis. It is taken once a week, not daily, and it needs regular blood tests.
Which one is right for you?
Choose Elidel if…
Choose for eczema on delicate skin — face, eyelids, folds — when you want to avoid steroid thinning.
- Eczema on the face or eyelids
- You need repeated or long-term treatment
- Age 2 or older
Choose Methotrexate if…
Choose for severe psoriasis, especially with joint pain, as an inexpensive weekly treatment with regular blood tests.
- Psoriasis with psoriatic arthritis
- Cost matters and biologics aren't covered
- You can avoid alcohol and keep up blood tests
Fine together
Can you take them together?
Elidel can be used on the face or folds while taking methotrexate. Very little Elidel reaches the blood.
At a glance
● Elidel
● Methotrexate
Type
Topical calcineurin inhibitor (pimecrolimus 1%)
Oral or injected immune suppressant
What it does
Calms the immune reaction without thinning skin
Calms overactive immune cells and skin-cell growth
Best for
Mild to moderate eczema on face, eyelids and folds
Severe psoriasis and psoriatic arthritis
Prescription
Yes
Yes
Form
Cream
Tablet or injection
How often
Twice daily
Once a week — never daily
Course length
Flares, or 2–3 times a week to prevent them
Ongoing
Time to results
1–6 weeks
4–12 weeks
Main side effect
Warmth or stinging at first
Nausea and tiredness the day after
Blood tests
None
Required
Pregnancy
Check with your clinician
Never
Cost
Moderate; generic available
Low; generic available
What it treats
Compare uses by strength of evidence. Evidence level describes confidence in a benefit, not its size.
Evidence level
Elidel
Methotrexate
Strong evidenceMost established uses
Psoriasis
Clears moderate to severe plaques.
Moderate evidenceSome supportive research
Seborrheic Dermatitis
A steroid-free option for the face.
Eczema
An option for severe eczema.
Psoriatic Arthritis
Reduces joint symptoms.
Limited evidenceEarly or small studies
Vitiligo
Can restore some color on the face.
—
Little evidence
Psoriasis
Too mild for plaques.
Alopecia Areata
Mixed results in small studies.
Not effective
Acne
No role in acne.
Acne
No role in acne.
How it works
Elidel
Diagram explanation and sources
Inhibits calcineurin: Blocks a switch that helps activate T cells. Reduces immune messengers: T cells release fewer inflammation-driving signals. Calms eczema and itch: Redness and irritation ease as inflammation settles.
The drug binds FKBP-12 and inhibits calcineurin, reducing T-cell cytokine transcription; the complete atopic-dermatitis mechanism is not known. It also has other cellular effects.
Methotrexate
Diagram explanation and sources
Interferes with cell replication: Blocks folate-dependent processes used to make DNA. May increase adenosine signaling: This calming messenger can limit immune-cell activity. Reduces skin inflammation: Inflammatory activity and plaque buildup can decrease.
The psoriasis mechanism is not fully established. Folate antagonism affects replication, while low-dose anti-inflammatory actions include proposed adenosine pathways supported by experimental work; their precise clinical contributions are unresolved.
How you take it
Treatment plan
When to Apply: A thin layer twice a day on the affected skin. Rub it in until it disappears. Moisturizer can go on top or underneath.
How to Start: Twice daily as soon as a flare starts, and keep going until the skin is clear rather than merely better. Many people then move to two or three days a week on the spots that always come back, to head off the next flare. Discuss that with your doctor.
If It Irritates: Warmth, stinging or burning for the first few days is the commonest complaint. It happens because the skin is inflamed, not because you are allergic, and it usually stops within a week as the eczema settles. Keeping the cream in the fridge, moisturizing first, or starting once a day for a few days makes it easier.
If It's Not Working: Nothing to increase — there is one strength. Give it six weeks of consistent twice-daily use. If the skin is no better, the usual next steps are a short steroid course to reset it, a switch to tacrolimus ointment, or a newer non-steroid cream.
This drug is taken once a week. Taking it every day can cause fatal bone marrow failure. Pick one day of the week, write it down, and keep to it.
Test dose: A single small dose, often 2.5 mg to 5 mg, with blood counts checked about a week later before going further. A safety check, not the treatment dose.
Starting dose: Commonly 7.5 mg to 15 mg once weekly, adjusted for age, weight, kidney function and other illnesses. Lower in older people and in reduced kidney function.
Going up: Small steps, usually 2.5 mg to 5 mg every few weeks with blood tests in between, until the psoriasis responds or side effects set the ceiling.
Usual dose: Most people settle between 15 mg and 25 mg once weekly. Above about 15 mg tablet absorption gets unreliable, a common point to switch to the injection.
Folic acid alongside it: It reduces nausea, mouth ulcers and blood count problems. Usually a daily dose on the days you are not taking methotrexate, or one larger weekly dose on a different day. It does not stop the drug working.
Total course: No fixed course. It continues as long as it works and blood tests stay normal, which for some people is years.
Monitoring
No routine blood tests. Blood levels are very low or undetectable, and it does not affect the adrenal glands the way strong steroids do.
Monitoring is a conversation at six weeks, then longer intervals if you stay on it. Your doctor is checking whether the eczema is actually controlled, whether steroid rescue courses have been needed often enough to suggest a change of plan, and whether any patch of skin is behaving oddly rather than simply eczema.
Because of the boxed warning, most dermatologists look harder at any new or changing spot in long-term users rather than assuming it is part of the rash. Registry follow-up has not found the increase in skin cancer or lymphoma the warning anticipated, so this is ordinary caution, not surveillance for a known risk.
Methotrexate is watched by blood test, and the schedule is not optional. The problems it causes are silent until they are advanced.
Before starting: Full blood count, liver tests, kidney function, and a pregnancy test where relevant. Hepatitis B, hepatitis C, HIV and tuberculosis screening is standard, because the drug damps the immune system. A chest x-ray if there is any history of lung disease.
Early on: Blood counts and liver tests within a week or two of starting, and again after each dose increase. This is when a sudden drop in blood counts would show.
Once stable: Full blood count, liver tests and kidney function every one to three months, depending on the dose and what else you take, for as long as you are on the drug.
The liver over the long term: Years of methotrexate can scar the liver, and the risk rises with total lifetime dose, heavy alcohol use, obesity, diabetes and fatty liver disease. Biopsy used to be the check; most clinics now use a blood marker of scarring and a scan of liver stiffness.
The lungs: A rare but serious lung inflammation can occur. A new dry cough, breathlessness or fever means being seen, not waiting for the next appointment.
What to report between tests: Mouth ulcers, unexplained bruising or bleeding, sore throat or fever, dark urine, yellowing of the eyes or skin, severe nausea, any new cough or breathlessness.
When to take it
Not covered in this guide yet
Once a week, on the same day every week. Choose a day you will remember and write it somewhere visible. Some people take the whole dose at once; some split it into two portions about twelve hours apart on the same day to reduce nausea. Do not spread it across different days unless you were told to.
Take tablets with water, and with food if they upset your stomach. An evening dose means the tiredness and mild nausea happen while you are asleep.
Folic acid goes on the other days, as prescribed. It is not a substitute for a missed methotrexate dose.
With the weekly injection, keep to the same day and rotate the site.
If you miss a dose
Not covered in this guide yet
Take it as soon as you remember if it is within about two days of your usual day. If longer, skip it and take the next on your usual day. Never take two weekly doses close together to catch up, and never take a daily dose to make up for a missed week.
If you have taken more than one weekly dose, or taken it several days in a row, contact a doctor or a poison center straight away. Do not wait to see how you feel. This overdose is treatable caught early and dangerous when it is not.
When you’ll see results
Approximate windows, not promises.
● Elidel
● Methotrexate
First few minutes
First few minutesApplying it: A thin layer twice a day. Warmth or stinging for a few minutes, strongest on the rawest skin.
Days 1 to 5
Days 1 to 5Adjusting: The stinging is at its worst now and fades as the skin heals. Itch often eases while the rash looks the same.
Weeks 1 to 2
Weeks 1 to 2Working: Redness fades, skin feels less tight. Night scratching drops off first.
Weeks 1 to 2Settling in: Nothing visible in the skin yet.
Weeks 2 to 6
Weeks 2 to 6Judge it here: The rash flattens and clears. The fair point to decide whether it is doing enough.
Face, eyelids and folds
Face, eyelids and foldsIts strongest use: Thin skin is where steroids cause the most trouble, so a non-thinning option is worth losing some strength. Armpits, groin and under the breasts thin quickly too.
Ongoing
OngoingHolding: Once clear, many drop to two or three applications a week on the areas that always flare. No thinning means no time limit.
First dose
First doseTaking it: Once a week, not daily, with folic acid on the other days. Nausea, tiredness or mouth soreness in the day or two after each dose is common early on; folic acid usually blunts it.
Weeks 4 to 8
Weeks 4 to 8Working: Plaques thin and spread less, thickness and scale first. Joint pain from psoriatic arthritis often improves in the same window, one reason it is chosen over a skin-only treatment.
About 3 months
About 3 monthsJudge it here: Substantial improvement is the realistic target.
Beyond 3 months
Beyond 3 monthsLong term: Where it suits, the result holds while the dose continues, with regular blood tests. Some stay on it for years.
Many months
Many monthsNails: Nail psoriasis can improve, but slowly. Nails always lag behind the skin.
Side effects
Sorted by what to do about them.
Elidel
Methotrexate
Common
Common
- Warmth, burning or stinging in the first days
- Flushing with alcohol
Common
- Nausea or tiredness the day after the dose
- Mouth sores
- Mild hair thinning
Tell your doctor
Tell your doctor
- Skin infection or cold sores
Tell your doctor
- Cough or breathlessness
- Fever, sore throat or unusual bruising
Stop and get care
Stop and get care
- Swollen glands or a lump that doesn't settle
Stop and get care
- Taking it daily by mistake
- Yellowing skin or dark urine
Safety and who should avoid it
Pregnancy
Use care
Ask the doctor managing your pregnancy.
Never
Both partners avoid conception during and for 3 months after.
Breastfeeding
Use care
Keep it off the breast and nipple.
Never
Not compatible.
Children
2 and older
Approved from age 2.
Specialist only
Used in children with monitoring.
Monitoring
None
Review at 6 weeks.
Required
Blood counts, liver and kidney tests; every 3 months once stable.
Key interactions
Check
Avoid light therapy and tanning.
Check
Trimethoprim-sulfamethoxazole, NSAIDs, some antibiotics; limit alcohol.
Other cautions
Avoid
Infected skin; weakened immune system.
Avoid
Liver disease, heavy drinking, kidney disease, active infection.
Cost and getting it
Getting it and cost
Cost has improved. Generic pimecrolimus cream brought the price down from one of the more expensive eczema treatments to something ordinary. Brand-name Elidel is still costly.
The usual obstacle is not price but step therapy. Because the label calls it second-line, many plans want to see that a topical steroid was tried and failed, or a reason a steroid should not be used, before covering it. A note from your doctor saying the eczema is on the eyelids or in the folds usually settles that.
Cash prices for the generic vary between pharmacies more than most drugs, so check a discount card price before assuming you cannot afford it. Tube size matters too — a large tube is often better value per gram, and eczema treatment runs longer than people expect.
Generic methotrexate tablets are among the least expensive systemic treatments in dermatology. Folic acid is cheap too.
The weekly auto-injector pens cost considerably more, and coverage usually requires showing that tablets caused nausea or did not work well enough. Plain injectable vials are cheaper than the pens.
The real cost is the monitoring, repeated blood tests and periodically a liver scan or blood marker. Usually covered, but they are appointments and not optional.
Insurers frequently require a trial of methotrexate before approving a biologic, one reason it is still so often the first systemic drug tried.
When you stop
Comes back?
Eczema can return; twice-weekly use on usual spots helps prevent flares.
Psoriasis usually returns over months.
Taper needed?
No.
Usually not, but plan the next step first.
After the last dose
No rebound and no skin thinning.
Wait at least 3 months before trying to conceive — applies to both partners.
Common questions
Elidel:Is pimecrolimus a steroid?
No. Different pathway, and it does not thin the skin — the whole reason it is used on eyelids, the face and skin folds.
Elidel:Why is there a cancer warning on the box?
Because at approval regulators noted that related medicines suppress immunity body-wide in transplant patients, that very high oral doses caused tumors in animals, and that a small number of cancer reports existed in users. The warning states that long-term safety is not established — a precaution, not a finding. Follow-up since has not shown an increased rate of skin cancer or lymphoma.
Elidel:Why does it burn when I put it on?
Because the skin underneath is inflamed. It is the commonest side effect, strongest in the first few days, and it settles as the eczema heals. Moisturizing first or chilling the tube helps.
Elidel:How long can I stay on it?
No fixed limit. It does not thin skin, so it can run in repeated courses, or two or three times a week, for years with review.
Elidel:Can I use it on my eyelids?
Yes — eyelids are one of its main uses, one of the few anti-inflammatory options that can go there repeatedly without thinning skin or raising eye pressure.
Elidel:Is it as strong as tacrolimus?
No. Tacrolimus 0.1% ointment is more powerful for moderate eczema. Pimecrolimus is better tolerated and cosmetically easier, so it is often the one people keep using.
Methotrexate:How often do I take it?
Once a week, on the same day. Never daily. Daily dosing by mistake is the most dangerous error with this drug and it has been fatal. Get medical help the same day if it happens.
Methotrexate:Why do I also have to take folic acid?
Methotrexate blocks folate, and the mouth ulcers, nausea and low blood counts come from that. Folic acid on the other days restores enough folate to reduce them without stopping the treatment working.
Methotrexate:Do I really need all the blood tests?
Yes. Liver damage and falling blood counts cause no symptoms until they are advanced. The tests are the only early warning.
Methotrexate:Can I drink alcohol?
The concern is regular drinking, not a single glass, because alcohol and methotrexate both stress the liver. Agree an actual limit with your doctor.
Methotrexate:Can I take it if I want to have a baby?
No. It must be stopped well before trying to conceive, and the advice covers both partners. It causes miscarriage and serious birth defects. Ask your own doctor how far in advance.
Methotrexate:How long before I know if it is working?
Give it about three months. First changes often show at four to eight weeks, but three months on a tolerated dose is the fair point to judge.
Methotrexate:Is it chemotherapy?
It is chemotherapy at much higher doses. At psoriasis doses it acts as an immune-calming drug, and the experience is not comparable.
Keep exploring.
Medication
Elidel
Medication
Methotrexate
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