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Psoriasis Provoked or Exacerbated by Medications: Identifying Culprit Drugs

Psoriasis Provoked or Exacerbated by Medications: Identifying Culprit Drugs A critical practice gap exists in identifying the causes of psoriasis flares, especially medication-related causes. Some physicians may not consistently examine medications for their contribution to psoriasis flares. However, a careful consideration of the role of medications in psoriasis exacerbation may improve long-term psoriasis control. Several factors are important in evaluating the role of medications in psoriasis flares: (1) medications can exacerbate preexisting psoriasis and/or induce psoriasis on clinically uninvolved skin in patients with psoriasis (the incidence of psoriasis exacerbation is generally greater than that of psoriasis induction); (2) the strength of evidence linking different medications with psoriasis flares varies considerably; and (3) the latency period between drug ingestion and psoriasis flares varies among medications and can be much lengthier for certain medications. Although many medications have been implicated in psoriasis flares, strong evidence exists linking β-blockers, lithium, antimalarials, and interferons. Medications with a possible link to psoriasis exacerbation include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, nonsteroidal anti-inflammatory drugs, and tumor necrosis factor inhibitors. β-Blockers are categorized into cardioselective or noncardioselective types, and both have been involved in psoriasis induction and exacerbation. The latency period from ingestion of β-blockers to psoriasis flares varies from several days to 12 months in patients with psoriasis.1 In patients without a history of psoriasis, regular use of β-blockers for 6 years or longer is associated with the development of psoriasis.2 Lithium has been more commonly associated with psoriasis exacerbation than induction. The mean latency period is 20 weeks for psoriasis exacerbation and 48 weeks for psoriasis induction. Antimalarials are associated with psoriasis exacerbation. Exacerbations are more frequently seen in patients treated with chloroquine than hydroxychloroquine. The latency period for antimalarial-exacerbated psoriasis is 4 to 12 weeks. Solutions to narrow gaps in identifying medication-related psoriasis flares include a careful review of a patient’s medication list with special attention to medications with strong evidence of contributing to psoriasis exacerbation. Furthermore, it is important for dermatologists to recognize medications with latency periods beyond the typical 2 to 4 weeks and to inquire about historical use of these medications with known long latency periods. More important, dermatologists need to critically evaluate the true probability that the medication contributes to the psoriasis exacerbation in the context of maturity of evidence and other non–medication-related causes of psoriasis exacerbation. Thus, hasty discontinuation of use of medications that have a low probability of contributing to psoriasis flares may be more aggressive than necessary. Barriers to change include a lack of recognition of medication-related psoriasis exacerbations by health care professionals. Additional barriers may include the inability and/or unwillingness to identify alternative therapies to the offending agent. For example, when a β-blocker is identified as highly probable in contributing to psoriasis exacerbation, selecting an alterative antihypertensive drug may deviate from guideline-based care. Thus, when dermatologists recommend discontinuation of use of a medication, they need to coordinate care with other health care professionals to ensure that the patient is offered appropriate alternative treatments for substitution. Narrowing this practice gap will help reduce medication-related psoriasis flares and significantly improve long-term outcomes in patients with psoriasis. Back to top Article Information Corresponding Author: April W. Armstrong, MD, MPH, Department of Dermatology, University of Colorado Denver, 12801 E 17th Ave, Mail Stop 8127, Aurora, CO 80045 (aprilarmstrong@post.harvard.edu). Published Online: July 2, 2014. doi:10.1001/jamadermatol.2014.1019. Conflict of Interest Disclosures: None reported. References 1. Basavaraj KH, Ashok NM, Rashmi R, Praveen TK. The role of drugs in the induction and/or exacerbation of psoriasis. Int J Dermatol. 2010;49(12):1351-1361.PubMedGoogle ScholarCrossref 2. Wu S, Han J, Li W-Q,Qureshi AA. Hypertension, antihypertensive medication use, and risk of psoriasis [published online July 2, 2014]. JAMA Dermatol. doi:10.1001/jamadermatol.2013.9957.Google Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Dermatology American Medical Association

Psoriasis Provoked or Exacerbated by Medications: Identifying Culprit Drugs

Armstrong, April W.
JAMA Dermatology , Volume 150 (9) – Sep 1, 2014
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Psoriasis Provoked or Exacerbated by Medications: Identifying Culprit Drugs

Abstract

A critical practice gap exists in identifying the causes of psoriasis flares, especially medication-related causes. Some physicians may not consistently examine medications for their contribution to psoriasis flares. However, a careful consideration of the role of medications in psoriasis exacerbation may improve long-term psoriasis control. Several factors are important in evaluating the role of medications in psoriasis flares: (1) medications can exacerbate preexisting psoriasis and/or...
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References (8)

Publisher
American Medical Association
Copyright
Copyright © 2014 American Medical Association. All Rights Reserved.
ISSN
2168-6068
eISSN
2168-6084
DOI
10.1001/jamadermatol.2014.1019
pmid
24989499
Publisher site
See Article on Publisher Site

Abstract

A critical practice gap exists in identifying the causes of psoriasis flares, especially medication-related causes. Some physicians may not consistently examine medications for their contribution to psoriasis flares. However, a careful consideration of the role of medications in psoriasis exacerbation may improve long-term psoriasis control. Several factors are important in evaluating the role of medications in psoriasis flares: (1) medications can exacerbate preexisting psoriasis and/or induce psoriasis on clinically uninvolved skin in patients with psoriasis (the incidence of psoriasis exacerbation is generally greater than that of psoriasis induction); (2) the strength of evidence linking different medications with psoriasis flares varies considerably; and (3) the latency period between drug ingestion and psoriasis flares varies among medications and can be much lengthier for certain medications. Although many medications have been implicated in psoriasis flares, strong evidence exists linking β-blockers, lithium, antimalarials, and interferons. Medications with a possible link to psoriasis exacerbation include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, nonsteroidal anti-inflammatory drugs, and tumor necrosis factor inhibitors. β-Blockers are categorized into cardioselective or noncardioselective types, and both have been involved in psoriasis induction and exacerbation. The latency period from ingestion of β-blockers to psoriasis flares varies from several days to 12 months in patients with psoriasis.1 In patients without a history of psoriasis, regular use of β-blockers for 6 years or longer is associated with the development of psoriasis.2 Lithium has been more commonly associated with psoriasis exacerbation than induction. The mean latency period is 20 weeks for psoriasis exacerbation and 48 weeks for psoriasis induction. Antimalarials are associated with psoriasis exacerbation. Exacerbations are more frequently seen in patients treated with chloroquine than hydroxychloroquine. The latency period for antimalarial-exacerbated psoriasis is 4 to 12 weeks. Solutions to narrow gaps in identifying medication-related psoriasis flares include a careful review of a patient’s medication list with special attention to medications with strong evidence of contributing to psoriasis exacerbation. Furthermore, it is important for dermatologists to recognize medications with latency periods beyond the typical 2 to 4 weeks and to inquire about historical use of these medications with known long latency periods. More important, dermatologists need to critically evaluate the true probability that the medication contributes to the psoriasis exacerbation in the context of maturity of evidence and other non–medication-related causes of psoriasis exacerbation. Thus, hasty discontinuation of use of medications that have a low probability of contributing to psoriasis flares may be more aggressive than necessary. Barriers to change include a lack of recognition of medication-related psoriasis exacerbations by health care professionals. Additional barriers may include the inability and/or unwillingness to identify alternative therapies to the offending agent. For example, when a β-blocker is identified as highly probable in contributing to psoriasis exacerbation, selecting an alterative antihypertensive drug may deviate from guideline-based care. Thus, when dermatologists recommend discontinuation of use of a medication, they need to coordinate care with other health care professionals to ensure that the patient is offered appropriate alternative treatments for substitution. Narrowing this practice gap will help reduce medication-related psoriasis flares and significantly improve long-term outcomes in patients with psoriasis. Back to top Article Information Corresponding Author: April W. Armstrong, MD, MPH, Department of Dermatology, University of Colorado Denver, 12801 E 17th Ave, Mail Stop 8127, Aurora, CO 80045 (aprilarmstrong@post.harvard.edu). Published Online: July 2, 2014. doi:10.1001/jamadermatol.2014.1019. Conflict of Interest Disclosures: None reported. References 1. Basavaraj KH, Ashok NM, Rashmi R, Praveen TK. The role of drugs in the induction and/or exacerbation of psoriasis. Int J Dermatol. 2010;49(12):1351-1361.PubMedGoogle ScholarCrossref 2. Wu S, Han J, Li W-Q,Qureshi AA. Hypertension, antihypertensive medication use, and risk of psoriasis [published online July 2, 2014]. JAMA Dermatol. doi:10.1001/jamadermatol.2013.9957.Google Scholar

Journal

JAMA Dermatology – American Medical Association

Published: Sep 1, 2014

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