Do non‑selective NSAIDs exacerbate psoriasis, and what analgesic alternatives are safe for a patient with psoriasis?

Do NSAIDs Exacerbate Psoriasis?

NSAIDs can trigger or worsen psoriasis in patients with existing disease and should be avoided when possible, though they may be used cautiously for short-term symptomatic relief of musculoskeletal manifestations in psoriatic arthritis only—not for skin disease. 1, 2

Evidence for NSAID-Induced Psoriasis Exacerbation

Guideline Consensus

• The American Academy of Dermatology explicitly recommends avoiding NSAIDs in patients with psoriasis because they can trigger or exacerbate psoriatic disease. 1
• NSAIDs are listed among major psoriasis-exacerbating medications alongside lithium, antimalarials, beta-blockers, and alcohol. 1, 3
• Multiple international guidelines acknowledge NSAIDs as documented triggers for psoriasis flares, though the mechanism remains incompletely understood. 4, 5, 6

Research Evidence

• A large cohort study (Nurses' Health Study II) following 95,540 women over 1.3 million person-years found that long-term NSAID use (>10 years) was associated with a hazard ratio of 2.10 (95% CI: 1.11-3.96) for developing psoriatic arthritis. 7
• NSAID use showed the strongest association with chronic kidney disease in psoriasis patients (adjusted OR 1.69,95% CI 1.14-2.49), which is particularly concerning given the renal comorbidity burden in this population. 8

Limited Role in Psoriatic Arthritis Management

When NSAIDs May Be Considered

• For psoriatic arthritis only: EULAR and American College of Rheumatology guidelines state NSAIDs "may be used to relieve musculoskeletal signs and symptoms" in psoriatic arthritis patients. 8, 2
• NSAIDs provide no disease-modifying benefit and have no demonstrated efficacy on skin lesions. 8
• Any benefit should be seen within a few weeks; NSAIDs should not be the only therapy beyond 3 months if active disease persists. 8

Critical Limitations

• NSAIDs carry the risk of worsening skin disease even when used for joint symptoms. 2
• When patients have insufficient response to NSAIDs for enthesitis, dactylitis, or axial disease, guidelines recommend escalating to biologic DMARDs rather than continuing NSAID therapy. 2

Clinical Algorithm for NSAID Use in Psoriasis Patients

For Psoriasis WITHOUT Psoriatic Arthritis

• Avoid NSAIDs entirely—they are contraindicated due to risk of triggering or exacerbating skin disease. 1, 2

For Psoriatic Arthritis WITH Active Skin Disease

• Use NSAIDs only as short-term bridging therapy while initiating DMARDs. 2
• Monitor closely for psoriasis flares (new lesions or worsening plaques). 2
• Transition to disease-modifying therapy (methotrexate preferred when skin involvement is clinically relevant). 8

For Psoriatic Arthritis WITH Minimal/Controlled Skin Disease

• NSAIDs may be used for symptomatic relief with strict limitations on duration and dose. 2
• Maintain vigilance for new skin lesions or worsening plaques. 2
• Consider intra-articular glucocorticoid injections as an alternative for monoarthritis/oligoarthritis. 8

Safe Analgesic Alternatives

Preferred Options

• Acetaminophen (paracetamol) for mild pain, though note that long-term use (>10 years) was associated with increased PsA risk (HR 3.60,95% CI: 2.02-6.41) in one cohort study—still safer than NSAIDs for short-term use. 7
• Intra-articular glucocorticoid injections for localized joint involvement or dactylitis (tendon sheath injection). 8
• Disease-modifying therapies (methotrexate 15-25 mg/week, biologics) address both joint and skin disease rather than relying on symptomatic analgesics. 8

Systemic Glucocorticoids

• May be used with caution at the lowest effective dose, though withdrawal can trigger pustular psoriasis flares. 8, 6

Critical Caveats

• Renal function monitoring is essential if NSAIDs are used, given the known impairment in renal function and increased CKD risk in psoriasis patients. 8
• Drug-induced flares typically occur in patients with pre-existing psoriasis rather than causing new-onset disease, though both scenarios are documented. 4, 5
• Pediatric patients are less likely to have psoriasis triggered by NSAIDs compared to adults. 1
• The clinical context matters: concomitant antipsoriatic therapy, infections, and other triggers (stress, alcohol) can confound the attribution of flares to NSAIDs alone. 5