Sixty-four patients with erosive hand osteoarthritis refractory to usual treatments were randomized to receive methotrexate (10 mg/week) (n=32) or placebo (n=32). The primary outcome was the change in pain intensity measured by a visual analogue scale (VAS) from baseline to 3 months. Secondary outcomes included pain VAS at 12 months, functional assessments (FIHOA and Cochin scores), radiographic structural changes (Verbruggen-Veys and Ghent University Score System), and MRI findings at 12 months. Overall, the results revealed no significant difference in pain reduction between methotrexate and placebo at 3 or 12 months. However, methotrexate-treated joints showed a significantly greater progression to the remodeling phase on radiographs (27% vs. 15%; p=0.03). These findings suggest that while methotrexate does not provide superior pain relief, it may have a modest impact on structural remodeling in erosive HOA.