What are the guidelines for using prednisone (corticosteroid) long-term in patients with severe psoriasis?

Long-term Prednisone Use in Psoriasis: Not Recommended

Systemic corticosteroids like prednisone are not recommended for long-term management of severe psoriasis due to the risk of rebound flares, potential for serious adverse effects, and availability of safer, more effective alternatives. 1, 2

Risks of Systemic Corticosteroids in Psoriasis

Systemic corticosteroids pose several significant concerns when used for psoriasis:

• Risk of skin flares/rebound: While evidence is limited to case reports, there is concern that skin psoriasis may flare when corticosteroids are tapered or discontinued 1
• Long-term adverse effects: Extended use can lead to:
  • Skin atrophy and striae
  • Osteoporosis and bone fractures
  • Adrenal suppression
  • Metabolic complications (diabetes, weight gain)
  • Cardiovascular risks (hypertension, edema)
  • Increased infection risk 3

Appropriate Treatment Algorithm for Severe Psoriasis

1. First-line Topical Therapies

• For mild-moderate disease (BSA <10%):
  • Topical corticosteroids (classes 1-5) for up to 4 weeks 1
  • Vitamin D analogs (calcipotriene) alone or in combination with corticosteroids
  • Calcineurin inhibitors for face and intertriginous areas 2

2. Second-line Therapies

For patients with inadequate response to topicals or BSA >10%:

• Phototherapy: Narrowband UVB or PUVA 2
• Traditional systemic agents:
  • Methotrexate (10-15 mg weekly)
  • Cyclosporine (short-term use)
  • Acitretin (especially for pustular variants) 2

3. Advanced Therapies

For patients with inadequate response to traditional systemics:

• Biologics:
  • TNF-α inhibitors (adalimumab, etanercept, infliximab)
  • IL-17 inhibitors (secukinumab, ixekizumab, brodalumab)
  • IL-23 inhibitors (guselkumab, risankizumab)
  • IL-12/23 inhibitor (ustekinumab) 1, 2, 4
• Small molecules:
  • PDE4 inhibitors (apremilast)
  • JAK inhibitors 2

Limited Role of Systemic Corticosteroids

According to the European League Against Rheumatism (EULAR), systemic glucocorticoids may be considered in specific circumstances:

• As a bridge therapy while waiting for other treatments to take effect
• For short-term control of severe flares
• At low doses (≤7.5 mg/day of prednisone equivalent)
• With caution in patients with extensive skin involvement 1

Combination Approaches

When systemic corticosteroids are deemed necessary:

• Always use with a DMARD (disease-modifying antirheumatic drug) to reduce risk of rebound 5
• Plan for tapering: "Drug-induced secondary adrenocortical insufficiency may be minimized by gradual reduction of dosage" 3
• Consider alternate-day therapy to minimize adverse effects 3

Monitoring Requirements

If systemic corticosteroids must be used:

• Monitor for skin disease worsening
• Regular blood pressure checks
• Blood glucose monitoring
• Bone density assessment
• Evaluate for signs of adrenal suppression 3

Key Pitfalls to Avoid

1. Monotherapy with corticosteroids: Never use systemic corticosteroids as monotherapy for psoriasis 5
2. Abrupt discontinuation: Always taper gradually to avoid rebound flares and adrenal crisis 3
3. Prolonged use: The longer the duration, the greater the risk of adverse effects 3
4. Failure to consider alternatives: Modern biologics and small molecules offer better safety profiles with superior efficacy for long-term management 4

In conclusion, while short-term, low-dose systemic corticosteroids may occasionally be used as bridge therapy in severe psoriasis, they should not be considered for long-term management due to unfavorable risk-benefit profile when compared to other available therapies.