Drug-induced psoriasis

Drugs that may exacerbate existing psoriasis include:

• lithium
• antimalarials such as chloroquine
• mepacrine
• NSAIDs
• beta-blockers
  • a review of French pharmacovigilance database between 1985 and 2019 found 225 reports of psoriatic conditions after beta-blocker exposure, with a reporting odds ratio of 8.95 (95%CI 7.75 to 10.33) (1)
    • mean time to onset of symptoms was 5 months
    • outcome was favourable in 68% after beta-blocker discontinuation
    • authors note this was a class effect
• alcohol
• interferons (2)
• imiquimod (2)
• terbinafine (2)

Drugs that have been reported to precipitate psoriasis in patients with no previous history of the disease include (2):

• lithium
• beta-blockers

Notes (2):

• more recently, new associations have been reported for monoclonal antibody- and small-molecule-based targeted therapies used for oncological and immunological indications, such as tumor necrosis factor-alpha antagonists and anti-programmed cell death protein 1 immune checkpoint inhibitors
• available evidence supporting the associations of drug-related psoriasis with various drugs is limited predominantly to anecdotal single-case reports or retrospective case series. Exceptions to this are beta-blockers, lithium, and tumour necrosis factor (TNF)-alpha antagonists, for which the associations with drug-related psoriasis were assessed in large-cohort studies or case-control studies
• management:
  • first step in the management of drug-related psoriasis is stopping and replacing the offending agent when possible
    • however, the psoriasis skin lesions may show no to minimal improvement upon treatment discontinuation of the suspected drug
    • when additional skin-directed therapy is needed, the treatment options that are normally available for psoriasis can be initiated
      • options include topical treatments with corticosteroids and/or vitamin D analogs, ultraviolet-based phototherapy and systemic treatments, such as methotrexate, acitretin, and fumaric acid esters, and biologics

References:

1. Azzouz, B et al Psoriasis risk after betablocker exposure: description of a pharmacovigilance signal. Br J Clin Pharmacol. 2022. Accepted Author Manuscript. https://doi.org/10.1111/bcp.15330
2. Balak DM, Hajdarbegovic E. Drug-induced psoriasis: clinical perspectives. Psoriasis (Auckl). 2017;7:87-94. Published 2017 Dec 7. doi:10.2147/PTT.S126727