In one of the “Complex Medical Dermatology” presentations at American Academy of Dermatology Virtual Meeting Experience 2021, Erik Stratman, MD, sifted through the fact or fiction regarding the use and safety of certain drugs in patients with psoriasis.

Point number one is to not overlook the medication list in patients with psoriasis. Dr Stratman noted other specialties are certainly not thinking about whether a prescribed or administered medication can induce psoriasis. There are three types of psoriasis reactions—de novo induction, existing disease flare, and psoriasiform—but it is not well studied and causation is difficult to establish.

Drugs associated with psoriasis flares can be broken into tiers based on the supporting evidence (eg, the “definites,” the “maybe nots,” and the “case reports”). The tier of most supporting evidence includes beta-blockers, lithium, antimalarials, and TNF antagonists.

In his practice, Dr Stratman said beta-blockers are the most common offender in drug-induced psoriasis. This may be simply because of the strong association of psoriasis with metabolic disease. Another drug with strong evidence, lithium, predominantly exacerbates existing psoriasis. Generally, time of onset takes an average 20 weeks to flare vs 48 weeks to induce. Similarly, hydroxychloroquine is more associated with plaque flares and takes an average 4 to 12 weeks to flare.

Dr Stratman shifted focus from the “definites” tier to prednisone and erythrodermic or pustular flares. Dermatologic training traditionally pegs systemic steroids as a significant risk factor for severe plaque psoriasis flaring. However, this notion was formed based on literature from the 1950s and 1960s; more recent reviews in the past decade indicate systemic corticosteroids are commonly used in psoriasis patients.

His research group recently completed a large review of adult patients with psoriasis seen over a 6-year period to examine the risk of flares with systemic corticosteroids. Patients were included if they had a previous diagnosis of psoriasis followed by at least one exposure to a systemic corticosteroid and at least one health system encounter during the study interval.

Upon analysis of the 516 included patients, 96% of the systemic corticosteroids were prescribed by a specialty other than dermatology. The most prescribed option was prednisone at 78%, and oral was the overwhelming route at first exposure (99%). Further, 266 (52%) of patients had one course of steroids and 250 (49%) had multiple courses. The median steroid dose was 40 mg.

In the group that received systemic corticosteroids, 16 flares were identified; 15 of those were worsening plaque psoriasis, one was erythrodermic, and zero were pustular. Six patients indicated their flares commenced prior to initiation of corticosteroids. Interestingly, the one case of erythrodermic psoriasis improved after beginning prednisone, possibly indicating their disease was set in motion before corticosteroid use, said Dr Stratman.  

In total, the overall flare rate was 1.42% (95% CI, 0.72-2.44), and the rate of severe psoriasis flare was 0.07% (95% CI, 0.00-0.26). Of these 16 patients with flares, six were on beta-blockers, one was taking hydroxychloroquine, and one was taking quinacrine, possibly backing up previously discussed “definites.”

So, Dr Stratman concluded, dermatologists should challenge the dogma that steroids significantly induce severe psoriasis flares in the general psoriasis population, as strict avoidance of systemic corticosteroids may be unnecessary.

Reference
Stratman EJ. Medications that may flare psoriasis: fact and fiction. Presented at: American Academy of Dermatology Virtual Meeting Experience 2021; April 23-25, 2021; virtual.