Psoriasis Triggers

Most people living with psoriasis experience good days when their skin clears and bad days when psoriasis flares. A trigger is usually needed to make psoriasis appear — whether it is for the first time or the thirtieth. Common psoriasis triggers are:

• Infection

• Reaction to Certain Medications

• Skin Injury

• Stress

• Weather

• Other (hormones, smoking, heavy alcohol consumption)

Infection
Studies show that some infections can trigger psoriasis. Dermatologists have seen people with a family history of psoriasis get strep throat and develop their first psoriasis lesions two weeks later. Strep throat often precedes an outbreak of guttate psoriasis. Inverse psoriasis is frequently aggravated by a thrush infection. Infections that can trigger psoriasis are:

• Candida albicans (thrush)

• Human immunodeficiency virus (HIV)

• Staphylococcal skin infections (boils)

• Streptococcal pharyngitis (strep throat)

• Viral upper respiratory condition

Treating the infection in many cases lessens or clears the psoriasis.

Reaction to Certain Medications
Some people develop psoriasis for the first time or experience a flare-up after taking certain medication. Medications that can trigger psoriasis are:

• Anti-malarial drugs. Dermatologists have seen people develop psoriasis for the first time after taking an anti-malarial medication.

• Beta-blockers (medication used to treat high blood pressure) and heart medication. These worsen psoriasis in some people.

• Corticosteroids. These medications, which range in potency from extremely mild to very strong, are used to treat psoriasis and can be very effective. It is important to use these medications as directed. Overuse and sudden withdrawal of some oral corticosteriods can aggravate psoriasis.

• Indomethacin (non-steroidal medication used to treat arthritis and other inflammatory conditions) worsens psoriasis in some people.

• Lithium (used to treat manic depression and other psychiatric conditions) aggravates psoriasis in about 50% of people who have psoriasis.

If you have psoriasis or a family history of psoriasis, be sure to let the doctor prescribing any of the above medications know. Other medications can sometimes be substituted.

Skin Injury
People with psoriasis often notice new lesions 10 to 14 days after the skin is cut, scratched, rubbed, or severely sunburned.

This is called the “Koebner phenomenon” and is named after Dr. Koebner who in the 19th century observed that a patient developed new lesions in areas where his horse bit him. This relationship between skin injury and developing new psoriatic lesions has been observed in many patients. Today, a wide range of traumas and skin conditions are known to trigger Koebner’s phenomenon:

Research shows that about 50% of people with psoriasis experience the Koebner phenomenon — developing a psoriatic lesion at the site of a skin injury or in the same place as another skin condition. About 10% of psoriasis patients develop a new psoriatic lesion each time the skin is injured. The likelihood of developing the Koebner phenomenon may increase when psoriasis lesions are already present.

Stress
Ask anyone with psoriasis what triggers a flare-up, and stress is likely to top the list. Scientific studies confirm that stress can worsen psoriasis and increase itching. Some people can even trace their first outbreak to a particularly stressful event.

Having psoriasis is, in itself, stressful. When lesions are visible, people may stare and not want to get near. They may ask, “What did you do to your skin?” Even a spouse, parents, children, friends, and co-workers can be visibly uncomfortable. Some people report that a spouse cannot bear to touch them during severe outbreaks. Others say they feel embarrassed or ashamed by their skin.

When psoriasis develops on the hands and feet, it is often difficult for people to perform daily tasks, such as picking up objects, typing, and walking. This can make holding a job or caring for a child extremely challenging. The itching and pain caused by psoriasis also makes daily life difficult.

Treating psoriasis can add to the stress. Some treatments are time-consuming. Broadband phototherapy requires three to five visits per week to a clinic, and narrowband requires two to three. Topical medications can be time-consuming to apply. After spending time and money to treat the psoriasis, a person may find the treatment ineffective. Potential side effects deter some people from opting for systemic medications, such as methotrexate and cyclosporine. The cost of treating psoriasis adds stress to many people’s lives. Some living with psoriasis find that they cannot afford to pay for the newer treatments, such as the biologics.

When the everyday stress of living with psoriasis is compounded by a stressful event at work, a personal crisis, or an especially hectic time, such as the holidays, the stress can feel overwhelming.

People may try to alleviate stress with an herbal or natural over-the-counter remedy. However, some food supplements and herbal remedies interact negatively with prescription medications. People also turn to alcohol and others drugs to reduce stress. Research shows that this actually increases stress.

Dermatologists recommend that their patients tell them if they feel overwhelming stress. There are many healthy ways to relieve stress. Many patients find that psychological counseling or joining a support group effectively reduces stress. Your dermatologist may be able to help you find a therapist or a support group. Some patients prefer to adopt a popular relaxation technique, such as meditation. Exercise also can help reduce stress.

Weather
Winter tends to be the most challenging season for people living with psoriasis. Numerous studies indicate cold weather is a common trigger for many people and that hot and sunny climates appear to clear the skin.

Cold winter weather is dry, and indoor heat robs the skin of needed moisture. This usually worsens psoriasis. Psoriasis can become even more severe when the stress of the holidays and winter illnesses combine to compromise immune systems.

While hot and sunny may help clear psoriasis, air-conditioning can dry out the skin and aggravate psoriasis. Moisturizing can help prevent this.

Other
Science has not uncovered all psoriasis triggers. Hormones, smoking, and heavy drinking appear to trigger psoriasis in some people.

How hormones affect psoriasis is still not well understood. Research shows that many people develop their first psoriatic lesions just after puberty when hormone levels fall. When hormones levels increase during pregnancy, psoriasis improves for many women. A recent study showed that 55% of pregnant women with psoriasis reported an improvement, 21% saw no change, and 23% experienced worsening. After delivery, only 9% reported improvement and 65% saw their psoriasis worsen. More research is needed to understand these effects.

Research suggests that localized (on the palms and soles) pustular psoriasis may be more common in people who smoke tobacco. Other studies suggest a correlation between smoking and developing plaque psoriasis. There also seems to be a link between smoking and developing severe psoriasis.

Quitting smoking improves psoriasis for some; however, quitting does not always clear the psoriasis. More research is needed in this area.

It is now believed that heavy drinking may trigger psoriasis in some people. Heavy drinking also may make treatment less effective. Again, more research is needed.

More Good Days than Bad
While there is no cure, psoriasis can be successfully managed so that one experiences more good days than bad. Numerous treatment options are available, and recent advances are revolutionizing the management and care of psoriasis. A dermatologist considers a patient’s overall health, age, lifestyle, and the severity of the psoriasis in order to find a treatment option that will achieve maximum effectiveness.

References:
Behnam SM et al. “Smoking and psoriasis.” SKINmed. 2005 May-June;4(3):174-176.

Bowcock AM et al. “Genetics of psoriasis: The potential impact on new therapies.” Journal of the American Academy of Dermatology. 2003 August;49(2):S51-55.

Murase, JE et al. “Hormonal Effect on Psoriasis in Pregnancy and Post Partum.” Archives of Dermatology. 2005 May;141(5):601-606.

For an overview, visit the AAD pamphlet Psoriasis and Psoriatic Arthritis.

Supported by an educational donation provided by Abbott.