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

Oral Steroids for Psoriasis

Systemic corticosteroids 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

Why Oral Steroids Are Contraindicated in Psoriasis

Oral corticosteroids like prednisone are generally avoided in psoriasis management for several critical reasons:

1. Rebound Phenomenon: When oral steroids are tapered or discontinued, psoriasis often returns with greater severity than before treatment.

2. Risk of Conversion: Withdrawal can trigger conversion to more severe forms of psoriasis, including:

   • Pustular psoriasis
   • Erythrodermic psoriasis (a medical emergency)

3. Long-term Safety Concerns: Systemic corticosteroids carry significant adverse effects with prolonged use 2:

   • HPA axis suppression
   • Increased infection risk
   • Cardiovascular effects
   • Metabolic disturbances

Limited Exception: Erythrodermic Psoriasis

In the specific case of erythrodermic psoriasis (a severe, potentially life-threatening form), short-term systemic steroids may be considered:

• Only as a brief intervention in severe, unstable cases
• Under close dermatologic supervision
• With a clear transition plan to steroid-sparing agents

According to the American Academy of Dermatology guidelines, for Grade 3 erythrodermic psoriasis (covering >30% BSA with moderate/severe symptoms), oral prednisone may be initiated at 1 mg/kg/day with tapering over at least 4 weeks 3.

Preferred First-Line Systemic Treatments for Severe Psoriasis

Instead of oral steroids, the following are recommended for moderate-to-severe psoriasis 3:

1. Cyclosporine (3-5 mg/kg/day)

   • Rapid onset of action
   • Particularly effective for erythrodermic psoriasis
   • Limited to 3-4 month "interventional" courses due to toxicity concerns

2. Methotrexate

   • Effective systemic option
   • Can be given subcutaneously to bypass liver metabolism
   • Caution in hepatic/renal disease

3. Biologic agents

   • TNF inhibitors (adalimumab, infliximab)
   • IL-17 inhibitors
   • IL-23 inhibitors
   • Ustekinumab

4. Acitretin

   • Slower onset of action
   • Not suitable for women of childbearing potential due to teratogenicity

Appropriate Use of Corticosteroids in Psoriasis

Corticosteroids still play an important role in psoriasis management, but primarily as topical therapy:

• Potency selection: Medium to high-potency (class 2-4) for most body areas; ultra-high potency (class 1) for thick, chronic plaques; low potency (class 6-7) for face, genitals, and intertriginous areas 1

• Application schedule: Twice daily for 2-4 weeks, followed by weekend-only application for maintenance 1

• Combination therapy: Often more effective when combined with vitamin D analogs, retinoids, or other agents 4

Clinical Pitfalls to Avoid

1. Prescribing oral steroids for routine psoriasis management despite their widespread use in clinical practice 5

2. Abrupt discontinuation of systemic steroids if they have been started, which can precipitate severe flares

3. Failure to monitor for steroid-related complications in patients receiving systemic therapy

4. Overlooking steroid-sparing alternatives that may provide safer long-term control

5. Neglecting combination approaches that can enhance efficacy while minimizing steroid exposure

In cases where systemic therapy is required for severe psoriasis, cyclosporine, methotrexate, or biologics should be considered as first-line options rather than oral corticosteroids.