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

Oral Steroids Should Be Avoided in Pustular Psoriasis Due to Risk of Disease Exacerbation

Oral steroids are contraindicated in pustular psoriasis as they can precipitate disease flares, exacerbate existing disease, and cause severe rebound phenomena upon withdrawal. 1

Risks of Oral Steroids in Pustular Psoriasis

• Systemic corticosteroids can precipitate erythrodermic psoriasis, generalized pustular psoriasis, or very unstable psoriasis when discontinued 1
• Oral corticosteroids have been documented to cause severe rebound phenomena in pustular psoriasis patients, even when they initially provide rapid improvement 2
• Recent research confirms that tapering and withdrawal of systemic corticosteroids can trigger psoriasis flare-ups and change morphology from nonpustular to pustular psoriasis 3
• In a survey of Danish dermatologists, 50% had observed at least one psoriasis flare-up following treatment with oral corticosteroids 3

Limited Indications for Systemic Corticosteroids in Psoriasis

Systemic corticosteroids should be restricted to only three rare and specific conditions:

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

Preferred Treatment Options for Pustular Psoriasis

First-line Treatments:

• Acitretin: Particularly effective for pustular psoriasis with response seen as early as 3 weeks (dosed at 0.1 to 1 mg/kg/day) 1
• Biologics:
  • Infliximab has shown rapid efficacy in severe generalized pustular psoriasis 1
  • Etanercept at 50 mg biweekly (not 25 mg) has demonstrated efficacy in generalized pustular psoriasis 1

Combination Approaches:

• Acitretin combined with narrowband UVB (NB-UVB) has shown synergistic effects in pustular psoriasis 1
• A case report demonstrated that adding NB-UVB to acitretin therapy allowed discontinuation of systemic steroids in a 3-year-old with refractory generalized pustular psoriasis 1

Management of Pustular Flares After Steroid Use

If a patient has already been started on oral steroids and is experiencing a flare during tapering:

• Do not abruptly discontinue steroids, as this may worsen the flare 1
• Consider initiating acitretin therapy (0.1-1 mg/kg/day) while slowly tapering the steroids 1, 4
• For severe cases, consider adding a biologic agent such as infliximab 1
• Bacterial culture should be obtained if infection is suspected, as secondary infection can complicate pustular psoriasis 2

Clinical Pitfalls to Avoid

• Misdiagnosis: Pustular psoriasis may be misdiagnosed as acute generalized exanthematous pustulosis (AGEP), leading to inappropriate steroid treatment 4
• Improper tapering: Too rapid withdrawal of corticosteroids can precipitate severe rebound flares 5
• Overlooking infections: Corticosteroids can mask signs of infection while increasing susceptibility to bacterial, viral, and fungal pathogens 5
• Prolonged use: Long-term systemic corticosteroid therapy has been confirmed to cause severe rebound phenomena in pustular psoriasis 2

Conclusion

When managing suspected pustular psoriasis, oral steroids should be avoided as they can trigger disease flares and cause severe rebound phenomena upon withdrawal. Instead, acitretin and biologics (particularly TNF inhibitors) should be considered as first-line systemic treatments, with combination therapy approaches often providing superior outcomes.