What is the role of oral steroids, such as prednisone, in the treatment of psoriasis?

Role of Oral Steroids in Psoriasis Treatment

Oral systemic corticosteroids are generally not recommended for the treatment of psoriasis as they can cause disease flares during or after tapering and may precipitate pustular or erythrodermic psoriasis. 1

Why Oral Steroids Are Avoided in Psoriasis

Oral corticosteroids present significant risks in psoriasis management:

• Rebound phenomenon: When oral steroids are tapered or discontinued, psoriasis can worsen significantly, often becoming more severe than the initial presentation 1, 2
• Disease transformation: Risk of converting plaque psoriasis into more severe forms such as pustular or erythrodermic psoriasis 2
• Lack of clinical trial data: No recommendation can be given regarding efficacy and side effect profiles due to absence of controlled clinical trials 1

Appropriate Corticosteroid Use in Psoriasis

Instead of oral steroids, the following approaches are recommended:

1. Topical Corticosteroids

• First-line treatment for limited psoriasis 1
• Potency selection based on location:
  • Class 6-7 (low potency) for face and intertriginous areas
  • Class 3-5 (medium potency) for body
  • Class 1-2 (high/ultrahigh potency) for thick plaques 2
• Duration: Limited to 4 weeks for most areas; longer use requires physician supervision 1
• Maximum weekly use: 50g or less for ultrahigh potency agents like clobetasol and halobetasol 1

2. Intralesional Corticosteroids

• Indicated for: Localized non-responding or very thick lesions on glabrous skin, scalp, nails, palms, and soles 1
• Dosing: Triamcinolone acetonide up to 20 mg/mL every 3-4 weeks 1

3. Steroid-Sparing Approaches

To avoid corticosteroid-related adverse effects, consider:

• Vitamin D analogs (calcipotriene, calcitriol): Often used in combination with topical corticosteroids 1, 2
• Topical calcineurin inhibitors (tacrolimus, pimecrolimus): Especially useful for facial and intertriginous areas 1
• Combination therapy: Using corticosteroids with other agents allows for intermittent steroid use, reducing risk of adverse effects 2

Special Circumstances

Psoriatic Arthritis

In severe psoriatic arthritis, low-dose oral prednisolone (10mg on alternate days) may be considered as adjunctive therapy with DMARDs like methotrexate, but only under close supervision and never as monotherapy 3. This approach should be reserved for cases where:

• NSAIDs have failed
• Joint symptoms are severe and rapidly progressive
• Biologics are unavailable or contraindicated

Severe Pustular or Erythrodermic Psoriasis

For severe, pustular, or erythrodermic psoriasis, short-term systemic corticosteroids may be considered under careful supervision, but further studies are needed to evaluate their role in these specific scenarios 1.

Monitoring and Risk Mitigation

If corticosteroids must be used:

• Never use as monotherapy for psoriasis
• Always taper gradually to minimize rebound
• Monitor for adverse effects: skin atrophy, telangiectasia, striae, HPA axis suppression
• Consider combination therapy with steroid-sparing agents

Conclusion

The evidence strongly discourages the routine use of oral corticosteroids for psoriasis management. Focus should be on established first-line therapies including topical treatments, phototherapy, and appropriate systemic agents like methotrexate, acitretin, cyclosporine, or biologics depending on disease severity and presentation.