Psoriasis exacerbation

Nowakowski J +, J Am Acad Dermatol 32, 223 Pruritus ani et vulvae Psoriasis (exacerbation)... 

Avoid skin trauma. Sunburns can induce a flare-up of psoriasis. Sunscreens with a sun protection factor of at least 15 should be routinely used when outdoors often a sun protection factor of 30 is recommended. Avoid scratching the skin, which could lead to excoriations and exacerbate psoriasis. Loose-fitting cotton garments should be worn to minimize skin irritation. 

Fever, rigors, chills, malaise headaches, myalgia Nausea, emesis Neutropenia Hepatic enzyme elevation Cutaneous—alopecia, transient, mild rashlike reaction Acetaminophen (APAP). NSAID if APAP is not effective. Meperidine for severe chills and rigors. Bedtime administration. 5-HT3 antagonist, prochlorperazine, metoclopramide, fluids Weekly complete blood count reduce dose by 30-50% Liver function tests (LFTs) weekly withhold treatment until LFTs normalize restart at 30-50% dose reduction reversible on dose reduction or cessation. Interferon is contraindicated in patients with psoriasis because exacerbation of psoriasis has been noted during IFN therapy. 

The overall effect of Li+ on the hematopoietic system is of stimulation of the immune system. Not surprisingly then, Li+ is reported to exacerbate the activity of a number of autoimmune diseases, such as psoriasis [212] and rheumatoid arthritis [213], and to result in the production of autoantibodies in some patients [214]. However, there is no evidence that Li+ s stimulation of the immune system leads to any reduction in the occurrence of viral or bacterial infections in patients on Li+ therapy. 

Psoriasis is a common chronic inflammatory disease characterized by recurrent exacerbations and remissions of thickened, erythematous, and scaling plaques. 

The medical history of a patient with psoriasis should include information about the onset and duration of lesions, family history of psoriasis, presence of exacerbating factors, previous history of antipsoriatic treatment (if any) along with efficacy and adverse effect data, exposure to chemicals and toxins, and allergies (food, drugs, and environmental). 

Other late-appearing lithium side effects include benign reversible leukocytosis, acne, alopecia, exacerbation of psoriasis, pruritic dermatitis, mac-ulopapular rash, folliculitis, and weight gain. 

Autoimmune disorders Development or exacerbation of autoimmune disorders, including myositis, hepatitis, idiopathic thrombocytopenic purpura, psoriasis, rheumatoid arthritis, interstitial nephritis, thyroiditis, and systemic lupus erythematosus have been reported in patients receiving alpha interferon. 

Psoriasis Use in patients with psoriasis may precipitate a severe attack. Porphyria may be exacerbated. Do not use unless the benefit to the patient outweighs possible risks. 

Hydroxychloroquine (Plaquenil), like chloroquine, is a 4-aminoquinoline derivative used for the suppressive and acute treatment of malaria. It also has been used for rheumatoid arthritis and discoid and systemic lupus erythematosus. Hydroxychloroquine has not been proved to be more effective than chloroquine. Adverse reactions associated with its use are similar to those described for chloroquine. The drug should not be used in patients with psoriasis or porphyria, since it may exacerbate these conditions. 

Dermatological reactions to lithium include acne, follicular eruptions, and psoriasis. Hair loss and thinning also have been reported. Except for cases of exacerbation of psoriasis, these reactions are usually benign and may not warrant discontinuation of lithium treatment. Lithium-induced acne responds to topical treatment with retinoid acid, such as tretinoin (Retin-A). 

Early in the course of lithium therapy, exacerbations of psoriasis and acneiform eruptions as well as other skin reactions may occur. Possible mechanisms have included lithium s ability to decrease cAMP as well as to increase the number and activity of polymorphonuclear leukocytes. Those with a predisposition to skin disorders are most at risk for this complication, with women more likely than men to experience a dermatological reaction to lithium. These problems may clear spontaneously or may require lithium dose reduction, appropriate dermatological intervention, or lithium discontinuation ( 77). 

Fisher DA, Elias PM, LeBoit PL. Exacerbation of psoriasis by the hypolipidemic agent, gemfibrozil. Arch Dermatol 1988 124(6) 854-5. 

Exacerbation of secondary hyperparathyroidism occurred in a 20-year-old renal transplant patient who also developed psoriasis during interferon alfa treatment (527). Both disorders resolved after withdrawal. 

Nitric oxide has a role in both acute and chronic inflammation. NOS-3 is involved in the vasodilation associated with acute inflammation. In experimental models of acute inflammation, inhibitors of NOS-3 have a dose-dependent protective effect, suggesting that nitric oxide promotes edema and vascular permeability. Nitric oxide has a detrimental effect in chronic models of arthritis dietary L-arginine supplementation exacerbates arthritis whereas protection is seen with NOS-2 inhibitors. Psoriasis lesions, airway epithelium in asthma, and inflammatory bowel lesions in humans all demonstrate elevated levels of nitric oxide and NOS-2. Synovial fluid from patients with arthritis contains increased oxidation products of nitric oxide, particularly peroxynitrite. 

These include atypical or subtle manifestations of dermatologic conditions such as seborrheic dermatitis, rosacea, psoriasis, atopic dermatitis, and ichthyosis. Classic manifestations of such diseases are diagnosed with relative ease. However, diagnostic difficulty arises in the presence of atypical morphology, lesions masked by topical therapy (e.g., corticosteroids), or exacerbations due to other topical agents (e.g., skin care products).2,10... 

Abel EA, DiCicco LM, Orenberg EK et al. (1986) Drugs in exacerbation of psoriasis. Journal of the American Academy of Dermatology 15 1007-1022. 

Mr GM took NSAIDs to alleviate the pain and irritation associated with his psoriasis. NSAIDs, such as ibuprofen and indometacin, have been shown to exacerbate psoriasis. Mr GM should be appropriately counselled in his use of pain medication. Further, the patient has failed to give treatment enough time to work in the past, citing associated pain and irritation of his condition. This may be due to the patient s use of ibuprofen, but also to the premature cessation of treatment. The patient should be counselled with regard to the duration of the treatments, and to the possible exacerbation of his condition should he cease treatment too soon. The provision of systemic drugs should be given with caution as, for example, premature cessation of systemic corticosteroid therapy will result in rebound deterioration of the condition. 

Notes Drugs associated with the exacerbation of psoriasis include lithium, beta-adrenergic receptor blocking agents and antimalarials. Withdrawal of corticosteroid therapy may activate pustular psoriasis. NSAIDs, such as ibuprofen... 

Miyagawa M, Shimoda K, Danno K, Kato N. Exacerbation of psoriasis during lithium treatment in a patient with bipolar I disorder. Int Chn Psychopharmacol 2000 15 368. 

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