Medications That Can Trigger Psoriasis

11 Drugs That Can Cause an Acute Flare

Psoriasis on a female eye
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Psoriasis is an autoimmune disease characterized by the spontaneous appearance of symptoms, known as flares, followed by periods of remission. There are many different conditions that can trigger flares, including stress, infection, skin injury, and even extreme temperatures. One of the more common triggers is drugs.

In addition to inciting a flare, certain medications can cause the onset of new disease or increase the duration or severity of existing symptoms. The reasons for this are unclear. Some drugs are believed to "switch on" the autoimmune response, while others appear to trigger the Koebner response (a phenomenon wherein a drug allergy can induce psoriasis at the site the rash).

Theoretically, any drug can trigger a psoriatic flare. But, there are certain drugs or drug classes strongly linked to the disease.

Beta-Blockers

Typically prescribed for high blood pressure, beta blockers are among the drugs most commonly linked to psoriasis. According to a 2010 review of studies in the Journal of Clinical and Aesthetic Dermatology, beta-blockers were considered a major factor in triggering severe psoriasis in people hospitalized for the disease. The drugs can also provoke new outbreaks in people previously undiagnosed.

Of the beta-blockers recognized as triggers, Inderal (propranolol) is the most common culprit. Unlike some drugs, beta-blockers are associated with a long period of latency, wherein the time between the start of treatment and the appearance of psoriasis can be months apart.

Oral beta-blockers are closely linked to plaque psoriasis and pustular psoriasis of the hands and feet. Topical beta-blockers used to treat glaucoma are closely tied to nail psoriasis.

Once a beta-blocker has caused a flare, it should not be used again unless the symptoms were mild and the benefits of treatment outweigh the risks.

There is high cross-reactivity between beta-blockers, meaning that a change of beta-blocker may not help. With that being said, some beta-blocker may be less problematic than others. The choice of appropriate treatment is largely based on trial and error.

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Lithium

Used to treat psychiatric illnesses such as bipolar disorder, lithium can trigger psoriasis in around 50 percent of people with known disease. Like beta-blockers, lithium tends to have a very long latency period. While lithium is most commonly linked to psoriatic flares, it can also cause the onset of plaque psoriasis, pustular psoriasis, psoriatic arthritis, and psoriasis of the scalp or nails.

If a psoriatic flare is triggered by lithium, a type of sugar known as inositol may significantly reduce the risk of future flares, says a 2017 review in the journal Psoriasis. Inositol is available in supplement form but should only be used under the direction of a doctor.

Older studies have also suggested that the daily intake of omega-3 fatty acids, found in oily fish, nuts, and nutritional supplements, may also reduce the risk of lithium-induced flares.

Given the importance of lithium in treating mood disorders, the drug would not be discontinued unless the psoriasis symptoms are unmanageable.

Antimalarials

Used to treat malaria as well as rheumatoid arthritis and lupus, antimalarial drugs are known to induce and aggravate psoriasis. Of the antimalarials commonly implicated, Plaquenil (hydroxychloroquine) and chloroquine pose the greatest risk. Most flares develop within weeks of starting treatment.

Chloroquine is closely linked to plaque psoriasis and pustular psoriasis. Both drugs are also known to prolong flares for months (particularly if there has been a pustular eruption). Chloroquine is also believed to exacerbate symptoms of psoriatic arthritis.

Once antimalarial treatment has been stopped, it may take up to a month for the psoriasis symptoms to resolve. Thereafter, the antimalarial drug should be avoided.

Interferons

Interferons are a class of drug often used to treat hepatitis C and other diseases. Both interferon-alpha and interferon-beta have well-known associations with psoriasis.

Interferon-alpha, used to treat viral hepatitis, leukemia, kidney, cancer, and melanoma, is linked to plaque psoriasis and, to a lesser degree, psoriatic arthritis. Interferon-beta, used multiple sclerosis, can induce a new psoriasis outbreak or exacerbate existing symptoms.

Generally speaking, if interferon-alpha or interferon-beta is indicated for treatment, it would only be discontinued if the psoriatic symptoms are intolerable.

Terbinafine

Terbinafine is a synthetic antifungal used to treat athlete's foot, jock itch, and other common fungal skin infections. Available in both topical and oral formulations, terbinafine has been linked to more widespread psoriatic flares.

These most commonly occur with the oral version, known by the brand name Lamisil, which can induce or exacerbate plaque psoriasis, generalized (all-body) pustular psoriasis, and inverse psoriasis. Topical preparations can do the same, most often in the region of drug application.

Should a flare or the new onset of symptoms occur, terbinafine should be stopped and the skin treated with topical corticosteroids and the vitamin D derivative calcipotriene.

ACE Inhibitors

Angiotensin-converting enzyme (ACE) inhibitors like Lotensin (benazepril) and Vasotec (enalapril) are used to control hypertension. Their association with psoriasis is less certain, although people over 50 appear to be at greatest risk.

While ACE inhibitors are believed to induce or exacerbate psoriasis, there is evidence that the effect may be limited to people a family history of psoriasis and specific genetic subtypes of the angiotensin-converting enzyme.

If a flare were to occur after taking an ACE inhibitor, the decision to continue or discontinue the drug would be made on a case-by-case basis.

TNF Blockers

Tumor necrosis factor (TNF) alpha antagonists, also known as TNF blockers, are a type of biologic drug used to treat Crohn’s disease, rheumatoid arthritis, and ankylosing spondylitis. They work by suppressing the production of TNF, a type of inflammatory compound closely linked to autoimmune diseases. These include such drugs as Humira (adalimumab), Enbrel (etanercept), and Remicade (infliximab)

The triggering of psoriasis by these drugs is considered paradoxical since psoriasis is also an autoimmune disease. With that being said, the drugs will often cause the worsening of symptoms in the first months of treatment before they eventually get better. During this time, changes in the immune response may trigger the appearance of psoriasis.

If psoriasis was to occur during treatment, the TNF blocker would only be stopped if the symptoms are severe. More likely, topical treatments would be used to minimize symptoms until immune control is achieved.

Other Drugs

In addition to the above-listed drugs, there are other medications that can trigger new or recurrent symptoms. These include:

  • Benzodiazepines like Xanax (alprazolam), Valium (diazepam), and Ativan (lorazepam)
  • Nonsteroidal anti-inflammatory drugs (NSAIDs), particularly Aleve (naproxen) and Tivorbex (indomethacin)
  • Tetracycline antibiotics like tetracycline, doxycycline, and minocycline

Corticosteroids like prednisone can also trigger psoriasis if stopped abruptly. To avoid this, the dose would need to be gradually tapered over weeks or months under the supervision of a doctor.

A Word From Verywell

To avoid psoriatic flares and other complications, be sure to advise your rheumatologist about any and all drugs you are taking. These include prescription, over-the-counter, and recreational drugs as well as supplements and herbal remedies.

If a psoriatic flare occurs, don't assume that a drug the cause and stop treatment. Instead, contact your rheumatologist to schedule a complete evaluation. If a drug is identified as the culprit, the dose may be adjusted or treatment stopped based on symptoms and/or medical needs.

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