What is the recommended treatment for psoriasis using prednisolone (corticosteroid)?

Prednisolone Use in Psoriasis: Guidelines and Recommendations

Systemic corticosteroids like prednisolone should NOT be used for routine treatment of psoriasis as they may precipitate severe flares upon withdrawal, including erythrodermic or generalized pustular psoriasis. 1

Appropriate Use of Corticosteroids in Psoriasis

Topical Corticosteroids

Topical corticosteroids are the mainstay of treatment for mild to moderate psoriasis:

• Potency selection:

  • Plaque psoriasis: Class 1 (ultrahigh-potency), class 2 (high-potency), or class 3-5 (medium-potency) corticosteroids recommended for up to 4 weeks 1
  • Scalp psoriasis: Class 1-7 corticosteroids recommended for initial and maintenance treatment 1
  • Face/intertriginous areas: Lower potency corticosteroids should be used due to risk of skin atrophy 1

• Duration:

  • Limited to 2-4 weeks for class I (ultrahigh-potency) corticosteroids 1
  • Gradual tapering recommended following clinical response 1
  • Longer use (>12 weeks) only under careful physician supervision 1

• Application frequency:

  • 1-2 times daily as monotherapy 1
  • Can be combined with other topical agents, UV light, or systemic agents 1

Systemic Corticosteroids (Prednisolone)

Systemic corticosteroids should be reserved for only three specific conditions 1:

1. Persistent uncontrollable erythroderma causing metabolic complications
2. Generalized pustular psoriasis of the von Zumbusch type when other drugs are contraindicated
3. Hyperacute psoriatic polyarthritis threatening severe irreversible joint damage

Risks and Considerations

Risks of Topical Corticosteroids

• Local adverse effects: skin atrophy, striae, folliculitis, telangiectasia, and purpura 1
• Higher risk areas: face, intertriginous areas, and chronically treated areas 1
• May exacerbate acne, rosacea, perioral dermatitis, and tinea infections 1

Risks of Systemic Corticosteroids (Prednisolone)

• Stopping treatment may precipitate erythrodermic psoriasis, generalized pustular psoriasis, or very unstable psoriasis 1
• Disease rebound upon withdrawal is a significant concern 1

Alternative Approaches

For mild to moderate psoriasis, consider these alternatives to systemic prednisolone:

• Topical non-steroid options:

  • Vitamin D3 analogs (calcipotriene) - effective in 6-8 weeks 2
  • Retinoids (tazarotene) - effective in 1-2 weeks 2
  • Calcineurin inhibitors (tacrolimus, pimecrolimus) - particularly useful for facial and intertriginous areas 1
  • Coal tar preparations (2-4 weeks) 2
  • Anthralin (2-4 weeks) 2

• Combination approaches:

  • Topical corticosteroids combined with vitamin D analogs or retinoids 2
  • Rotational or sequential regimens to minimize side effects 2

Special Considerations

• Psoriatic arthritis: In severe cases, low-dose prednisolone (e.g., 10 mg on alternate days) may be used in combination with DMARDs like methotrexate for short periods 3, but should not be used as monotherapy

• Monitoring: When topical corticosteroids are used, regular clinical review is essential with no unsupervised repeat prescriptions 1

• Tapering: Always taper systemic corticosteroids gradually if they must be used, to prevent rebound flares 1

Clinical Pearls

• 46% of psoriasis patients in academic practices receive Class I (ultrapotent) topical steroids, often as adjuncts to systemic therapy 4

• For patients with mild to moderate psoriasis, intermittent topical corticosteroid therapy (e.g., weekend-only application) may be effective for maintenance in chronic stages 2

• Always consider the location, severity, and type of psoriasis when selecting appropriate corticosteroid potency and formulation