What drugs can exacerbate psoriasis?

Drugs That Exacerbate Psoriasis

Beta-blockers, lithium, antimalarials (chloroquine/hydroxychloroquine), and non-steroidal anti-inflammatory drugs (NSAIDs) are the primary medications that can exacerbate psoriasis, with lithium, chloroquine, and mepacrine potentially causing severe or life-threatening deterioration. 1

Major Psoriasis-Exacerbating Medications

Strong Evidence for Causation

• Lithium - Can cause severe, even life-threatening deterioration of psoriasis 1
• Antimalarials - Chloroquine and mepacrine (hydroxychloroquine) can severely worsen psoriasis 1, 2
  • FDA labeling specifically warns: "Administration of hydroxychloroquine sulfate to patients with psoriasis may precipitate a severe flare-up of psoriasis" 2
  • Chloroquine similarly warns: "Use of chloroquine phosphate tablets in patients with psoriasis may precipitate a severe attack of psoriasis" 3
• Beta-blockers - Can exacerbate pre-existing psoriasis or trigger new onset 1, 4
  • Mechanism involves decreased cyclic adenosine monophosphate (cAMP) levels affecting keratinocyte proliferation 4
  • Long-term use (≥6 years) shows stronger association with psoriasis development 1
• Non-steroidal anti-inflammatory drugs (NSAIDs) - Can worsen existing psoriasis 1, 5

Other Medications with Reported Associations

• Tetracyclines - Occasionally reported to exacerbate psoriasis 6, 7
• Alcohol - Can precipitate or worsen psoriasis 1
• Systemic corticosteroid withdrawal - May trigger pustular psoriasis 5
• TNF inhibitors - Paradoxically can trigger psoriasis in some patients 1

Clinical Presentation and Mechanisms

• Drug-induced psoriasis can present as:

  • Exacerbation of pre-existing psoriasis
  • New psoriatic lesions on previously uninvolved skin
  • De novo psoriasis in predisposed individuals 6, 7

• Mechanisms vary by medication:

  • Beta-blockers: Affect intracellular calcium and decrease cAMP, leading to increased keratinocyte proliferation 4
  • Antimalarials: Direct irritant effect on keratinocytes 2, 3
  • Lithium: Alters inflammatory mediators and cellular signaling 7

Management Recommendations

• Discontinue the offending medication when possible and substitute with an alternative that doesn't affect psoriasis 6
• Monitor closely after discontinuation as some medications (particularly antimalarials) may cause continued progression of psoriasis even after stopping 2, 3
• Consider dermatology consultation for patients with severe psoriasis requiring systemic agents 1
• Avoid prescribing known psoriasis-exacerbating drugs in patients with a history of psoriasis unless the benefit clearly outweighs the risk 2, 3

Special Considerations

• Pediatric patients - Triggering medications like beta-blockers, lithium, antimalarials, NSAIDs, and tetracyclines are rarely inciting agents in children compared to adults 1
• Severity assessment - Consider both objective measures (body surface area) and patient's perception of disability when evaluating drug-induced psoriasis 1
• Hypertension management - While beta-blockers can exacerbate psoriasis, the preponderance of evidence does not support avoiding all antihypertensive medications in psoriasis patients 1