Do NSAIDs Trigger or Exacerbate Psoriasis? [Response to Letter]

Dear editor

We appreciate Dr. Shaikh’s insightful comments on our narrative review on drug-induced psoriasis.^1,2 While we acknowledge that previous studies have suggested a link between non-steroidal anti-inflammatory drugs (NSAIDs) and the onset or exacerbation of psoriasis, the evidence supporting a causal role of NSAIDs in drug-induced and drug-aggravated psoriasis remains limited.³

The review of Fry et al, referenced by Dr. Shaikh, highlights studies dating from the 1980s that report anecdotal associations between psoriasis exacerbations and the use of topical and oral indomethacin.⁴ However, these studies lack robust data to confirm causality. The case-control and case-crossover study by Cohen et al reported an association between NSAID use and psoriasis in patients hospitalized with severe disease.⁵ However, important confounders, such as NSAID use for psoriatic arthritis, were not taken into consideration, leaving room for potential bias. Similarly, the cited reference of Grau et al, available only as a conference abstract, was based on an uncontrolled telephone questionnaire, making it highly susceptible for recall and prescription biases.⁶

Of note, a large cohort study from the Nurses’ Health Study (NHS) found no significant association between regular NSAID use and an increased risk of developing psoriasis.⁷

Taken together, we believe that the current body of evidence does not warrant advising against the use of NSAIDs in psoriasis patients.³ In line with this, current clinical guidelines continue to recommend NSAIDs as a first-line treatment option for managing psoriatic arthritis.⁸