Can Acute Respiratory Illness Trigger Psoriatic Arthritis Flare-Ups?
Yes, acute respiratory illness can trigger psoriatic arthritis flares, with documented evidence showing that SARS-CoV-2 infection specifically causes flares through multiple mechanisms including treatment discontinuation, inflammatory triggering, and antimalarial drug use. 1
Mechanisms of Respiratory Illness-Induced Flares
The National Psoriasis Foundation COVID-19 Task Force explicitly recognizes three pathways by which respiratory infections trigger psoriatic disease flares: 1
- Direct inflammatory triggering from the infection itself activates cytokine pathways (TNF, IL-6, IL-17) that overlap with psoriatic disease pathophysiology 1
- Treatment discontinuation during acute infection removes disease control, allowing flare development 1
- Antimalarial drug exposure (hydroxychloroquine/chloroquine) used for COVID-19 treatment can precipitate flares, though clinical significance remains uncertain 1
Clinical Evidence and Case Reports
COVID-19 has been documented to both trigger new-onset psoriatic arthritis and cause flares in established disease: 2, 3
- A 2022 case report demonstrated COVID-19 infection triggering refractory psoriatic arthritis requiring certolizumab pegol for remission after glucocorticoids and methotrexate failed 2
- Another 2022 case documented the first reported instance of concomitant psoriasis and psoriatic arthritis development following COVID-19 infection 3
- The cytokine storm pattern in severe COVID-19 mirrors the pro-inflammatory profile seen in psoriatic arthritis, providing biological plausibility 3
Management During Acute Respiratory Infection
When psoriatic arthritis patients develop acute respiratory illness, immunosuppressive therapy decisions must balance infection control against flare risk: 1
- Hold immunosuppressive treatments during suspected or confirmed SARS-CoV-2 infection on a case-by-case basis, recognizing this may precipitate flares 1
- Monitor symptoms closely and maintain communication with rheumatology/dermatology providers throughout the infection 1
- Systemic corticosteroids should NOT be withheld for severe COVID-19 management despite flare risk, as mortality benefit outweighs psoriasis concerns 1
Resumption of Therapy Post-Infection
Restart psoriatic arthritis treatments after complete symptom resolution in most cases: 1
- Wait for fever resolution for 24 hours without antipyretics and improvement in respiratory symptoms 1
- Minimum 10-day isolation from symptom onset before considering treatment resumption 1
- Severe hospital courses require individualized shared decision-making with specialists before restarting immunosuppression 1
Critical Pitfalls to Avoid
Do not assume all respiratory infections carry equal flare risk - the evidence specifically documents COVID-19, though biological plausibility exists for other viral respiratory illnesses 1, 2, 3
Do not continue hydroxychloroquine or chloroquine for COVID-19 treatment in psoriatic disease patients outside clinical trials, as these drugs can trigger flares without proven COVID-19 benefit 1
Do not delay systemic corticosteroids in severe respiratory illness due to flare concerns - mortality reduction takes precedence over psoriasis management 1
Recognize that recurrent respiratory infections in psoriatic arthritis patients on immunosuppression may indicate underlying immunodeficiency requiring evaluation, even in adults 4