Is prednisone effective for treating psoriasis?

Prednisone for Psoriasis: Limited Role and Significant Risks

Systemic corticosteroids like prednisone should NOT be used for routine treatment of psoriasis due to the high risk of disease rebound, flares, and conversion to more severe forms upon withdrawal. 1

Appropriate Uses of Corticosteroids in Psoriasis

Systemic Corticosteroids

Systemic corticosteroids should be reserved for only three specific and rare conditions:

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

Topical Corticosteroids

Topical corticosteroids are highly effective first-line treatments for psoriasis:

• Potent and very potent topical corticosteroids show greater efficacy than mild/moderate ones 1
• Class I-III steroids demonstrate 68-72% improvement rates in controlled studies 1
• Topical application should be limited to 2-4 weeks to minimize adverse effects 2

Intra-articular Corticosteroids

For psoriatic arthritis, localized joint injections may be beneficial:

• Can be used judiciously to treat persistently inflamed joints 1
• Care must be taken to avoid injection through psoriatic plaques 1
• Should be repeated with caution according to clinical judgment 1

Risks of Systemic Corticosteroids in Psoriasis

Despite being widely prescribed in clinical practice 3, systemic corticosteroids pose significant risks:

• Stopping treatment may precipitate erythrodermic psoriasis, generalized pustular psoriasis, or very unstable psoriasis 1
• Approximately 50% of dermatologists and 29% of rheumatologists have observed psoriasis flare-ups following oral corticosteroid treatment 4
• About 10% of dermatologists and rheumatologists report psoriasis flares after intramuscular or intra-articular corticosteroid use 4

Treatment Algorithm for Psoriasis

1. Mild to moderate plaque psoriasis:

   • First-line: Topical corticosteroids (potency based on location) 1
   • Apply 1-2 times daily for 2-4 weeks 1
   • Gradually taper frequency after clinical improvement 2
   • Consider combination with vitamin D analogs for enhanced efficacy 2

2. Moderate to severe plaque psoriasis:

   • First-line: Phototherapy (UVB/PUVA) 1
   • Second-line: Methotrexate, fumaric acid esters, or TNF inhibitors 1
   • Third-line: Acitretin, alefacept, sulfasalazine 1
   • NOT prednisone or other systemic corticosteroids

3. Psoriatic arthritis:

   • Mild: NSAIDs and targeted intra-articular corticosteroid injections 1
   • Moderate/Severe: DMARDs (methotrexate, leflunomide, sulfasalazine) 1
   • Resistant cases: TNF inhibitors 1
   • Low-dose prednisolone (10mg alternate days) may be considered as adjunctive therapy with methotrexate in severe cases 5, but should not be used as monotherapy

Important Precautions

• When systemic corticosteroids must be used, implement careful monitoring and gradual tapering 1
• 44% of physicians take special precautions when treating psoriasis patients with systemic corticosteroids 4
• For topical corticosteroids, be aware of potential local side effects including skin atrophy, striae, folliculitis, telangiectasia, and purpura 2
• Tachyphylaxis may develop with long-term use of topical corticosteroids 1

Special Considerations

• For scalp psoriasis, betamethasone valerate 0.12% foam has shown 72% improvement after 4 weeks 2
• For facial and intertriginous areas, consider topical calcineurin inhibitors instead of corticosteroids to avoid skin atrophy 1
• When using topical corticosteroids long-term, consider weekend-only therapy or combination with non-steroidal agents to minimize adverse effects 6

Despite widespread use in clinical practice, the evidence strongly advises against systemic corticosteroids for routine psoriasis management due to the significant risk of disease exacerbation upon withdrawal.