Psoriasis
Clears moderate to severe plaques.
Hydrocortisone vs Methotrexate
Hydrocortisone: The mildest topical steroid, and the only one sold without a prescription. It is the usual starting point for the face, for skin folds and for young children. 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 Hydrocortisone if…
Choose as the first step for mild rashes on the face, folds or young children — the only steroid sold without a prescription.
- A mild, itchy rash
- The face, skin folds or a young child
- You want to start over the counter
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?
Hydrocortisone can be used on the face or folds while taking methotrexate. They do not interact.
At a glance
● Hydrocortisone
● Methotrexate
Type
Mild topical steroid (class 7)
Oral or injected immune suppressant
What it does
Calms inflammation and itch
Calms overactive immune cells and skin-cell growth
Best for
Mild eczema, bites and rashes on the face, folds and children
Severe psoriasis and psoriatic arthritis
Prescription
0.5–1% over the counter; 2.5% by prescription
Yes
Form
Cream or ointment
Tablet or injection
How often
Twice daily
Once a week — never daily
Course length
1–2 weeks
Ongoing
Time to results
1–2 weeks
4–12 weeks
Main side effect
Rarely any
Nausea and tiredness the day after
Blood tests
None
Required
Pregnancy
Check with your clinician
Never
Cost
Low; generic and OTC
Low; generic available
What it treats
Compare uses by strength of evidence. Evidence level describes confidence in a benefit, not its size.
Evidence level
Hydrocortisone
Methotrexate
Strong evidenceMost established uses
—
Moderate evidenceSome supportive research
Eczema
Calms mild flares.
Insect Bites
Reduces itch and swelling.
Contact Dermatitis
Calms mild rashes.
Eczema
An option for severe eczema.
Psoriatic Arthritis
Reduces joint symptoms.
Limited evidenceEarly or small studies
Diaper Rash
Short use for inflamed rashes.
—
Little evidence
—
Alopecia Areata
Mixed results in small studies.
Not effective
Psoriasis
Too mild for plaques.
Acne
No role in acne.
Can make it worse
Ringworm
Steroids let fungus spread.
Perioral Dermatitis
Steroids worsen it.
—
How it works
Hydrocortisone
Diagram explanation and sources
Activates steroid receptors: Binds receptors inside skin and immune cells. Turns down inflammatory signals: Changes gene activity to reduce inflammatory messengers. Eases redness and itch: Swelling and irritation settle as inflammation falls.
Simplified glucocorticoid receptor-mediated effects in steroid-responsive skin inflammation. Full effects also involve other pathways. No claim of antimicrobial action or cure; formulation and potency affect clinical use.
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: Twice a day, on the rash only, on clean dry skin. A thin film that makes the skin look shiny is enough. One fingertip unit, the amount along the last joint of an adult index finger, covers about two adult palms. Moisturizer can go on a few minutes before or after.
How to Start: Twice daily from day one, until the rash is flat rather than merely better. Usually three to seven days. Two weeks is the outer limit for one stretch without seeing a clinician, less on the face.
If It Irritates: Stinging on application is usually the base, not the steroid, and is more likely on broken skin or from an alcohol-containing gel or spray. An ointment often settles it. Itch or redness that worsens over days can mean an allergy to something in the product, which does happen with steroids.
If It Is Not Working: Stop after about a week and reassess. A rash that does not respond to hydrocortisone is often not eczema. Ringworm, a yeast rash in a fold and psoriasis all look plausible and all need something different.
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 blood tests are needed for ordinary short courses in a healthy adult. Monitoring means looking at the skin: did the rash clear, has the skin gone thin or shiny, have small blood vessels appeared, are stretch marks forming in the folds.
Children absorb proportionally more because they have more skin surface for their size, so a doctor watches how much is used and over how large an area. Anyone applying a steroid to large areas most days for months should be under review rather than repeating over-the-counter purchases.
Hydrocortisone is not a drug to stay on continuously. Where a condition needs ongoing control, the plan is short bursts for flares, emollients doing the daily work, or a switch to a treatment designed for maintenance.
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.
● Hydrocortisone
● Methotrexate
First few minutes
First few minutesApplying it: A thin layer on the affected skin. The mildest steroid strength, which is why it is sold over the counter.
Days 1 to 2
Days 1 to 2Itch first: Itching and stinging ease before the rash looks different, the earliest sign it is working. Insect bites and minor irritation settle in a day or two, and that is the whole course.
Days 3 to 7
Days 3 to 7Clearing: Redness fades and the skin flattens. A mild eczema flare settles here; cracked skin takes longer than skin that was only red. Weeping or crusting should be settling, not spreading.
Weeks 1 to 2
Weeks 1 to 2Judge it here: A mild rash should be gone or nearly gone. Contact dermatitis clears steadily once the trigger is gone.
Weeks 1 to 2Settling in: Nothing visible in the skin yet.
Weeks 2 to 4
Weeks 2 to 4Mild seborrheic dermatitis: Redness and flaking around the nose and brows improve.
After stopping
After stoppingMarks stay behind: Brown or gray patches where the rash was are pigment change, not scarring. They fade over weeks to months.
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.
Hydrocortisone
Methotrexate
Common
Common
- Rarely any at this strength
Common
- Nausea or tiredness the day after the dose
- Mouth sores
- Mild hair thinning
Tell your doctor
Tell your doctor
- A rash that spreads or changes (possible fungus)
- Spots around the mouth
Tell your doctor
- Cough or breathlessness
- Fever, sore throat or unusual bruising
Stop and get care
Stop and get care
- Spreading rash with fever
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 nipple before a feed.
Never
Not compatible.
Children
Use care
Under 2 only on medical advice.
Specialist only
Used in children with monitoring.
Monitoring
None
See a doctor if no better in 1 week.
Required
Blood counts, liver and kidney tests; every 3 months once stable.
Key interactions
None known
—
Check
Trimethoprim-sulfamethoxazole, NSAIDs, some antibiotics; limit alcohol.
Other cautions
Avoid
Ringworm, perioral dermatitis, rosacea, infected skin.
Avoid
Liver disease, heavy drinking, kidney disease, active infection.
Cost and getting it
Getting it and cost
Hydrocortisone is cheap. Store-brand 1% cream is the same drug at the same strength as the branded tube, usually for much less. Anti-itch versions with added ingredients cost more without treating the inflammation any better.
Prescription 2.5% is generic and also cheap, though the visit costs more than the tube. Ointments and creams are the cheapest vehicles. Foams and sprays cost more.
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 flare again; moisturizer helps hold it.
Psoriasis usually returns over months.
Taper needed?
No for short courses.
Usually not, but plan the next step first.
After the last dose
See a doctor if the rash returns quickly.
Wait at least 3 months before trying to conceive — applies to both partners.
Common questions
Hydrocortisone:How long can I use hydrocortisone?
About a week at a time on the body for an over-the-counter tube, less on the face. A rash that needs it longer than two weeks is a reason to be seen, not to buy more.
Hydrocortisone:Can I use it on my face?
For a few days, yes, and it is the mildest option there. Facial skin is thin and absorbs well, so weeks of daily use causes thinning, redness and small bumps around the mouth.
Hydrocortisone:Is 1% strong?
No. It is the bottom of the potency ladder. If a week of it has not worked, question the diagnosis.
Hydrocortisone:Will it thin my skin?
A short course on the body will not. Thinning comes from stronger steroids over long periods, especially on the face, eyelids, groin and armpits. Early changes usually recover over months. Stretch marks are permanent.
Hydrocortisone:Can it lighten my skin?
It can. Pale patches on treated skin show up more on deeper skin tones, and usually fade slowly after stopping. Untreated inflammation also leaves light and dark marks, so avoiding treatment is not a way around it.
Hydrocortisone:Can I use it on a fungal rash or on my child's diaper rash?
Not on its own. A steroid makes ringworm and yeast harder to recognize while they keep spreading. Diaper areas are covered, so absorption is higher, worth having a child's rash there looked at.
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
Hydrocortisone
Medication
Methotrexate
Compare
Eucrisa vs Hydrocortisone
Compare
Eucrisa vs Methotrexate
Compare
Methotrexate vs Otezla
Compare
Calcipotriene vs Methotrexate
Compare
Clobetasol vs Hydrocortisone
Compare
Clobetasol vs Methotrexate
Compare
Cyclosporine vs Hydrocortisone
Compare
Cyclosporine vs Methotrexate
Compare
Desonide vs Hydrocortisone
Compare