Psoriasis, Ibuprofen and NSAIDs

NSAIDs (non-steroidal anti-inflammatory drugs) such as Ibuprofen and naproxen, are a first-line treatment for managing pain and inflammation in mild psoriatic arthritis (PsA), including joint stiffness and swelling. Whilst they provide symptom relief, they do not prevent progressive joint damage or disease progression. Recently, concerns have been raised about the possibility that NSAIDs used in the treatment of psoriatic arthritis, may actually make the skin component worse, or even initiate it.¹

To address this, we will consider three separate, though related questions:

1. Do NSAIDs – including ibuprofen – initiate psoriasis or PsA in generally healthy individuals who have neither psoriasis nor PsA?

There is some evidence that certain drugs can act as a trigger for the onset of psoriasis and, by extension, PsA, in individuals who may already be predisposed to the condition. A comprehensive 2017 review did not, however, list NSAIDs among them.²

Data from the large cohort Nurses' Health Study II (NHS II), covering 1991–2005, suggest that long-term (>10 years), regular use of NSAIDs, is associated with an increased risk of developing psoriatic arthritis (PsA) in women, though there was no significant association with skin psoriasis.³ No comparable studies exist in men.

For the moment, we can say that there is very little evidence to suggest that NSAIDs initiate psoriasis or PsA in healthy individuals.

2. In those who have PsA without skin lesions and are using NSAID’s for symptomatic relief, can NSAIDs initiate psoriasis?

Evidence would suggest that NSAIDs can induce psoriasis in those taking NSAIDs for PsA alone.  However, only around 15% of patients with PsA do not have visible skin psoriasis, and most will eventually go on to develop the skin manifestations of the disease. Hence the role of NSAIDs in inducing skin disease in this small group of patients is impossible to determine, given that most of them would have developed skin disease anyway.

3. In those with both psoriasis and PsA, can NSAIDs worsen the skin lesions?

The answer to this question is yes, but probably only in susceptible individuals. The likely biological mechanism is that NSAIDs block some critical metabolic pathways leading to an accumulation of a group of molecules known as leukotrienes, which promote skin inflammation. However, available studies show mixed results, largely because many were carried out in the 1980s and were of poor quality.  

In one large report of 462 patients with psoriasis, the use of oral NSAIDs resulted in a worsening of skin lesions in six (1.3%).⁴ Note, however, that this report was based on an uncontrolled telephone questionnaire, making it highly susceptible to recall bias. In another study, 1% indomethacin cream applied topically, exacerbated psoriasis in 14 out of 20 patients.⁵ However, this study was based on patients who were already in hospital for severe disease. Moreover, in a study of 80 patients with PsA, taking an NSAID, there were no reports of any worsening of the skin condition.⁶

Thus, whilst there is evidence that some NSAIDs may worsen psoriasis in patients with PsA, the risk is very difficult to quantify and likely to be confined to susceptible individuals.

It is important to note that the much more significant risk associated with NSAID usage, is their gastrointestinal side-effects – including gastric ulcer, erosion and haemorrhage.⁷  For this reason, those taking NSAIDs such as ibuprofen for PsA, should take a proton pump inhibitor (PPI), such as lansoprazole or omeprazole, to protect to stomach and gut.

Conclusion

Previous studies have suggested a link between NSAIDs and the onset or exacerbation of psoriasis and PsA.  However, much of this evidence is from the 1980s and is little more than anecdotal. There is actually little evidence that NSAIDs have a causal relationship with either psoriasis or PsA and whilst they may exacerbate existing skin lesions in some individuals, the risk does not appear to be high. Moreover, evidence would suggest that most patients with PsA would be happy to trade a small deterioration in skin symptoms for the significant pain relief that NSAIDs undoubtedly provide.

For that reason, current clinical guidelines continue to recommend NSAIDs – such as ibuprofen – as a first-line treatment for managing PsA.⁷

​This seems reasonable, the only caveat being the need to prescribe concomitant PPIs to prevent unwanted gastrointestinal effects.

Author:
Dr David Ashton PhD MD
March 2026

Scientific references:

1.Shaikh S. NSAIDs: Unveiling Their Role in Drug-Induced Psoriasis [Letter].Psoriasis (Auckl), 2024; 14:101–102

2.Balak DMW, Hajdarbegovic E. Drug-induced psoriasis: clinical perspectives. Psoriasis (Auckl), 2017; 7:87-94

3. Wu S, Han J, Qureshi AA. Use of aspirin, non-steroidal anti-inflammatory drugs, and Acetaminophen (paracetamol), and risk of psoriasis and psoriatic arthritis: a cohort study. Acta Derm Venereol. 2015;95:217–223.

4.Grau R, Weidner K. Drug-induced psoriasis – A retrospective chart review performed at the university of Oklahoma department of dermatology. J Am Acad Dermatol. 2008; 58: AB127

5.Cohen AD, Bonneh DY, et al. Drug exposure and psoriasis vulgaris: Case-control and case-crossover studies. Acta Derm Venereol. 2005;85:299–303.

6.P. Sarzi-Puttini, S. Santandrea, L. et al. The role of NSAIDs in psoriatic arthritis: Evidence from a controlled study with nimesulide. Clin Exp Rheumatol 2001; 19 (Suppl. 22): S17-S20.

7. Tai FWD, McAlindon ME. Non-steroidal anti-inflammatory drugs and the gastrointestinal tract. Clin Med (Lond). 2021;21:131-134