Macrolides for Psoriasis Treatment
Macrolides are not recommended as first-line therapy for psoriasis, as there is insufficient high-quality evidence supporting their efficacy for this condition. While some small studies show potential benefits, current dermatology guidelines do not include macrolides among standard psoriasis treatments.
Evidence Assessment
Guideline Recommendations
Current psoriasis treatment guidelines do not include macrolides as recommended therapies for psoriasis:
The 2022 GRAPPA guidelines for psoriatic arthritis treatment make no mention of macrolides for skin manifestations, instead recommending topical agents, phototherapy, oral therapies (methotrexate, cyclosporine, PDE4 inhibitors, JAK inhibitors), and biologics (TNF inhibitors, IL-17 inhibitors, IL-12/23 inhibitors, IL-23 inhibitors) 1.
The 2009 American Academy of Dermatology guidelines for psoriasis management with traditional systemic agents only mention tacrolimus (a macrolide) in the context of organ transplant rejection prophylaxis, not as a standard psoriasis treatment 1.
Research on Macrolides in Psoriasis
Limited research suggests some potential benefit:
A small open-label study from 2007 with 60 patients showed that oral erythromycin combined with topical corticosteroids produced greater PASI score reductions than topical corticosteroids alone after 4 weeks 2.
Another small open trial from 2000 with 17 patients showed a statistically significant reduction in PASI scores from 22.8 to 13.7 with macrolide treatment 3.
A 2019 review article noted that macrolides showed some decrease in PASI scores in plaque-type psoriasis, likely through immunomodulatory mechanisms rather than antibacterial effects 4.
Mechanism of Action
Macrolides may affect psoriasis through:
- Inhibition of pro-inflammatory cytokines (IL-6, IL-8, TNF-alpha)
- Suppression of transcription factors like nuclear factor-kappaB
- Reduction of neutrophil activity
- Immunomodulatory effects beyond their antimicrobial properties 2, 5
Safety Considerations
If considering macrolides for psoriasis, be aware of these important safety concerns:
Cardiac effects: Macrolides can prolong QT interval and increase risk of cardiac arrhythmias, particularly in patients with existing heart disease, electrolyte abnormalities, or those taking other QT-prolonging medications 1.
Gastrointestinal effects: Common side effects include nausea, vomiting, abdominal pain, and diarrhea 1.
Antimicrobial resistance: Long-term macrolide use contributes to bacterial resistance, which is a significant public health concern 1.
Drug interactions: Macrolides can interact with many medications through cytochrome P450 inhibition 1.
Clinical Approach
For patients with psoriasis seeking treatment:
First consider established first-line therapies according to disease severity:
- Mild-moderate: Topical agents (corticosteroids, vitamin D analogs, retinoids)
- Moderate-severe: Phototherapy, conventional systemic agents (methotrexate, cyclosporine), biologics
If considering macrolides as adjunctive therapy (not first-line):
- Perform baseline ECG to exclude prolonged QTc interval
- Check for drug interactions with current medications
- Monitor for cardiac and gastrointestinal side effects
- Limit treatment duration to minimize antimicrobial resistance
Conclusion
While some small studies suggest macrolides might have modest benefits in psoriasis through anti-inflammatory mechanisms, the evidence is insufficient to recommend them as standard therapy. Established treatments with stronger evidence should be prioritized for managing psoriasis to improve morbidity, mortality, and quality of life outcomes.