How Your Environment May Cause Psoriasis Flare-Ups—and What to Do About It
Many people with psoriasis find that their flare-ups are triggered by a particular environmental factor. Most common factors are related to lifestyle—obesity, smoking, alcohol or stress, for example—or health exposures—HIV, physical trauma, some medications, or even strep infection, says board-certified dermatologist Nicole Seminara, M.D., from NYU Langone Health in New York City.
The National Psoriasis Foundation also includes allergies, diet, and the weather in its list of common environmental triggers, but Seminara says there’s not “much evidence” that those definitely cause flare-ups.
What is clear is that psoriasis triggers aren’t the same for everybody. Stress might cause one person’s psoriasis to flare up, while another person’s symptoms get worse during cold weather. Here’s a deeper look at each of the most common environmental triggers—and how to avoid or reduce them.
Not everyone who is obese—defined by the World Health Organization as having a BMI (body mass index) of 30 or more—develops psoriasis. In fact, some studies have suggested that psoriasis may actually lead to obesity, likely due to pronounced social isolation, poor eating habits, depression, increased alcohol consumption, and decreased physical activity.
The scientific jury is still out, but epidemiological studies provide strong evidence that obesity predisposes patients to psoriasis and increases psoriatic inflammation. For instance, a 2017 study published in Journal of Investigative Dermatology indicated that obesity and high abdominal fat mass doubled a person’s risk of psoriasis.
A 2015 study published in the British Journal of Dermatology found that people with psoriasis who lost weight by exercising and following a low-calorie diet saw their symptoms improve by almost 50 percent in 20 weeks—without changing anything in their medication or treatment plan. If you think losing weight might help your psoriasis symptoms, speak to your doctor to create a safe weight-loss plan.
A 2000 study, published in Cutis, looked at the impact of various lifestyle factors on psoriasis, including smoking. After establishing that smoking has a negative effect on psoriasis, researchers divided participants into two groups, based on whether they had ever had remissions or a period when their psoriasis disappeared completely. The results found that 78 percent of people who had experienced remissions were non-smokers, and of those who never experienced a remission, 66 percent were smokers.
Another study, published in 2013 in the Sultan Qaboos University Medical Journal, found a strong association between smoking and a type of pustular psoriasis called palmoplantar pustulosis.
One possible explanation for the link between smoking and psoriasis is that nicotine changes the immune system and skin-cell growth, and it interferes with the body’s immune response. The National Psoriasis Foundation says quitting smoking may help improve psoriasis symptoms. If you need help to quit, your doctor can recommend the right cessation program for you.
So far, there’s not a lot of data on a possible link between vaping and psoriasis, but one 2017 study, published online in the American Thoracic Society's American Journal of Respiratory and Critical Care Medicine, found that e-cigarettes appear to trigger unique immune responses as well as the same ones triggered by regular cigarettes. This suggests that e-cigarettes pose the same psoriasis risk as regular cigarettes.
Alcohol may affect psoriasis in a number of different ways, but the exact relationship is unknown.
“It is suggested that excess alcohol consumption can affect the immune system, upregulate pathways and products of inflammation, and increase susceptibility to infection, all of which are implicated in the development of psoriasis,” says Alia Ahmed, M.D., a psycho-dermatologist in the U.K.
A 1990 study, published in the British Medical Journal, found that young and middle-aged men who drink heavily were at a higher risk for psoriasis. And a 2016 review of three Nurses’ Health Studies (between 1976 and 2016), published in the American Journal of Public Health, linked excessive alcohol intake, particularly beer drinking, to an increased risk of developing psoriasis.
A 2019 review article published in Psoriasis: Targets and Therapy concluded that more research is needed to establish whether alcohol can induce or worsen psoriasis.
Dr. Ahmed says that unless there is a medical reason or potential interaction with a drug, she doesn’t typically advise her psoriasis patients to avoid alcohol completely. Instead, she suggests sticking to health guidelines for the general population. That’s up to one drink per day for women and two drinks per day for men, per the 2015-2020 U.S. Dietary Guidelines for Americans.
However, if Dr. Ahmed thinks a patient has issues with alcohol excess or they describe flares aggravated by alcohol, she suggests cutting down or stopping under medical guidance.
Experts believe that stress can manifest as the initial presentation of psoriasis, or cause an acute worsening of the condition. “The term 'stress' can encompass several things, for example, bereavement, relationship breakdown, loss of employment, family problems, infections and lifestyle factors,” Dr. Ahmed says. “These triggers can directly impact the skin through our body's stress response. The most common question I ask my patients is ‘What was happening in your life around the time your skin started to flare?’ Very often, they describe one of the triggers mentioned.”
A 2019 study published in the British Journal of Dermatology found a modest link between the loss of a partner and that person developing psoriasis and atopic dermatitis during the subsequent three months, which provides some evidence that acute stress could be a trigger for these conditions.
Many types of medication are associated with triggering psoriasis, including lithium, which is used to treat bipolar disorder and other psychiatric disorders; antimalarials like quinacrine, chloroquine, and hydroxychloroquine (Plaquenil); and the heart medication Quinidine, according to the National Psoriasis Foundation.
Additionally, the high blood pressure medication Inderal has been found to worsen psoriasis in about 25 percent to 30 percent of patients with psoriasis, per a 2010 article published in The Journal of Clinical and Aesthetic Dermatology.
If you start taking a medication and then develop psoriasis for the first time, or experience a flare-up, consult with your general physician or dermatologist.
Injury to Skin
Psoriasis plaques can appear on areas of the skin that have been injured or traumatized. This is called the Koebner phenomenon after the dermatologist Heinrich Koebner, who first described this response in 1876.
Various types of injury can trigger a flare-up, including vaccinations, insect bites, sunburns, and scratches. The good news is that the Koebner phenomenon can be treated in the same way as you would normally treat psoriasis symptoms if it is caught early enough.
Generally, doctors believe that anything that can affect the immune system can affect psoriasis. For example, a streptococcal infection (strep throat) is associated with guttate psoriasis. An earache, bronchitis, or respiratory infection may also lead to a flare-up in some people.
“Throat infections are a common trigger for psoriasis,” Ahmed says. “The mechanism is not entirely clear, but it may be that the immune reaction triggered by the infection results in an inflammatory response that is seen in the skin.”
It’s very difficult to avoid infections, but Ahmed suggests that if you get frequent throat infections, you may benefit from a tonsillectomy.
Although the immune system appears to play a key role in both allergies and psoriasis, there’s no solid research to confirm that allergies somehow trigger psoriasis flare-ups. However, people with psoriasis are more likely to have a large number of inflammatory mast cells in their skin, which are the kind of cells that trigger allergic reactions like hives and itching, in the skin. This explains why people with psoriasis may notice a worsening of their symptoms at the same time as their seasonal allergies are flaring.
Although there’s no scientific data to prove that weather triggers psoriasis flare-ups, many people with psoriasis report a worsening of their symptoms during cold weather. But it’s not all bad news on the weather front. “Natural sunlight is helpful to treat psoriasis, so that's a positive environmental exposure,” Seminara says.
Whether there’s solid scientific evidence to back up a direct link, you may find that one or more environmental factors worsen your psoriasis symptoms. It’s always a good idea to keep your general physician or dermatologist in the picture. Let them know of any changes you experience in your symptoms, so that you can work together to get the very best treatment plan for your condition.