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A recent study by Bronckers et al.[1] compared methotrexate and biologic agents in children from North America and Europe with plaque psoriasis. This retrospective study analyzed 234 children with moderate-to-severe psoriasis who received at least 3 months of either therapy. The mean age at the start of systemic therapy was 11.6 years in the methotrexate-only group and 13.3 years in the biologic agent-only group. Treatment response was assessed using Psoriasis Area and Severity Index (PASI) and Physician Global Assessment (PGA) at the baseline and within the next 6 months. Methotrexate was used in 69.7%, while biologics were administered to 20.1% of the patients. In 10.2% of patients, two treatment modalities were given sequentially (methotrexate followed by biologics in all but one patient). Patients receiving methotrexate were younger at treatment initiation and had a shorter interval between diagnosis and initiation of systemic therapy. Etanercept was the most frequently used biologic (in 73.2% of the patients who received biologics). More than 75% reduction in PASI (PASI75) was achieved in 40% of the patients on methotrexate and 71.4% of the patients on biologics. For those who were prescribed single-agent methotrexate treatment, the mean start and maximum dose of methotrexate were 0.28 mg/kg and 0.36 mg/kg, respectively. The mean start and maximum dose were 0.24 mg/kg and 0.29 mg/kg, respectively, in those who received methotrexate as sequential therapy. Clear or almost clear PGA was achieved in 35.6% of the patients who received methotrexate and 48.6% of the patients on biologic agents. Decreased mean PASI and PGA scores were associated with biologics more than with methotrexate (PASI effect: −3.13 and PGA effect: −0.31). After 5 years of use, drug survival rates were 35.9% and 57.1% for methotrexate and biologics, respectively. Better confounder-corrected drug survival was associated with biologics than methotrexate (hazard ratio [HR]: 2.23). Discontinuation owing to the lack of response was comparable with both the modalities (HR: 1.64).