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Home Topics A–Z Drug-induced psoriasis

Drug-induced
psoriasis
Author: Brian Wu, MD candidate, Keck School of
Medicine, Los Angeles, USA. DermNet New Zealand
Editor in Chief: Hon A/Prof Amanda Oakley,
Dermatologist, Hamilton, New Zealand. Copy editor:
Maria McGivern. June 2017.

Table of contents
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What is psoriasis?

Psoriasis is a common chronic skin condition

characterised by symmetrically distributed,
well-defined scaly plaques. The most common
type of psoriasis is chronic plaque psoriasis,
which often starts in early adult life.

What is drug-induced psoriasis?

In some people, psoriasis is drug-induced or

drug-aggravated.

In drug-induced psoriasis, discontinuation

of the o!ending drug leads to the clearance
of psoriasis. It occurs in patients with no
previous history of psoriasis.
In drug-aggravated psoriasis, the disease
continues to develop even after the
causative drug has been discontinued. It
typically occurs in patients with a personal
or family history of psoriasis.

These forms of psoriasis di!er from

psoriasiform drug eruption, a group of papular
drug eruptions characterised histologically by
epidermal hyperplasia and hypergranulosis.

Psoriasis induced by lithium

Psoriasis induced by Psoriasis induced by

lithium lithium

Psoriasis induced by
lithium

Who gets drug-induced

psoriasis?

As with psoriasis that is not induced by a drug,

drug-induced psoriasis occurs more frequently
in patients with a history of:

Obesity
Smoking
Diabetes
Hypertension
Dyslipidaemia (metabolic syndrome).

Other risk factors for psoriasis include:

Race — psoriasis occurs in all races, but it is

more common in Caucasians than in those
of African descent
A family history of psoriasis
Age — the most common ages for the onset
of psoriasis are 16–22 years and 57–60
years.

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What causes drug-induced

psoriasis?

The most common drugs to induce or

aggravate psoriasis are:

β-blockers (in 20% of patients with 

psoriasis, eg, propranolol, metoprolol,
bisoprolol)
Lithium (in 50% of patients with psoriasis)
and less often, other medications that are
given to improve mood
Antimalarial drugs (eg, hydroxychloroquine,
chloroquine, quinacrine)
Antibiotics (eg, amoxicillin —  but it may be
the infection for which the antibiotic is
prescribed that is the cause)
Non-steroidal anti-inflammatory drugs
(NSAIDs) including indomethacin and
aspirin
Angiotensin-converting enzyme (ACE)
inhibitors
Tumour necrosis factor-alpha (TNF-α)
inhibitors, for more information see
paradoxical psoriasis.

Other common triggers for psoriatic

exacerbations include trauma, sunburn,
streptococcal infection, human
immunodeficiency virus (HIV) infection and
emotional stress.

What are the clinical features of

drug-induced psoriasis?

Drug-induced or drug-aggravated psoriasis

may induce:

Localised plaque psoriasis, often a!ecting

scalp, knees, elbows, buttocks and/or
genitals
Generalised plaque psoriasis, with scattered
plaques on all parts of the body
Erythroderma when the entire skin surface
is red and scaly.

Acute generalised exanthematous pustulosis

(AGEP) is a severe drug-induced eruption that
closely resembles generalised pustular
psoriasis.

Palmoplantar pustulosis can also be drug-

induced, often by tumour necrosis factor
inhibitors. Although closely related,
palmoplantar pustulosis is no longer classified
as a type of psoriasis. It nearly always occurs in
smokers.

How is drug-induced psoriasis

diagnosed?

Diagnosis of drug-induced psoriasis can be

challenging when patients are on multiple
medications. The onset of psoriatic symptoms
can be months or years after the drug has
been started. Careful patient history is
essential in any patient that presents with
new-onset psoriasis and must include their
current medications. The possibility of other
triggers for psoriasis, apart from drugs, should
also be taken into consideration.

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How is drug-induced psoriasis

treated?

The standard of care in the case of drug-

induced psoriasis is to discontinue the
o!ending drug. However, this is not always
possible; for example, in a patient with severe
depression that is well controlled by lithium
where other options have been ine!ective or
contraindicated.

Treatments for psoriasis include:

Emollients
Topical corticosteroids
Vitamin D analogues such as calcipotriol
Phototherapy
Acitretin
Immune modulators such as methotrexate,
ciclosporin, mycophenolate
Biologics.

What is the outcome for drug-

induced psoriasis?

While some cases of drug-induced psoriasis

can resolve within weeks of stopping the
causative medicine, in other cases, it can take
much longer to resolve or not resolve
completely.

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References

Abel, EA. Diagnosis of drug-induced

psoriasis. Semin Dermatol 1992;11:
269–74. PubMed.
Kim GK, del Rosso JQ. Drug-induced
psoriasis: is it drug-induced or drug-
aggravated? J Clin Aesthet Dermatol
2010; 3: 32–8. PubMed Central.
Schalock PC. Psoriasis. Merck Manuals.
2016. Available at:
www.merckmanuals.com/professional/
dermatologic-disorders/psoriasis-and-
scaling-diseases/psoriasis (accessed 19
October 2016).
Buckley L, et al. Abstract #1816.
Psoriasis associated with anti-tumor
necrosis factor-alpha therapies in
children with inflammatory bowel
disease, juvenile idiopathic arthritis, and
chronic noninfectious osteomyelitis.
Presented at: American College of
Rheumatology/Association of
Rheumatology Professionals Annual
Meeting; Nov. 9-13, 2019; Atlanta.
Meeting news.

On DermNet

Psoriasis
Chronic plaque psoriasis
Plaque psoriasis
Generalised pustular psoriasis
Paradoxical psoriasis
Adverse cutaneous drug reactions
Drug eruptions
Drug-induced psoriasis
Antimalarial medications in
dermatology

Other websites

Hong J, Bernstein D. A review of drugs

that induce or exacerbate psoriasis.
Psoriasis Forum. 2012 (PDF file).  

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Dermatology Made Easy book

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