Are topical steroids allowed in the treatment of pustular psoriasis?

Topical Steroids in Pustular Psoriasis Treatment

Topical corticosteroids are allowed and can be effective in the treatment of localized pustular psoriasis, particularly for palms and soles, but should be used with caution due to potential adverse effects and risk of rebound. 1

Appropriate Use of Topical Steroids in Pustular Psoriasis

• Moderate potency topical corticosteroids may provide symptomatic relief for localized pustular psoriasis affecting palms and soles 1
• Topical corticosteroids are considered the cornerstone of treatment for the majority of patients with limited psoriasis, with efficacy rates ranging from 41% to 92% depending on potency class 2
• For short-term management, more potent agents can be used to achieve initial response, followed by intermittent use for long-term management 2
• Topical steroids should be used with caution and for limited duration in pustular psoriasis to minimize risk of adverse effects 2

Important Precautions and Limitations

• Abrupt withdrawal of topical corticosteroids can cause rebound effects, potentially worsening pustular psoriasis 1
• Extensive application of potent topical steroids over large psoriatic areas should be avoided due to risk of systemic absorption that could potentially induce or worsen generalized pustular psoriasis 3
• Common adverse effects include skin atrophy, striae, folliculitis, telangiectasia, and purpura, which may further complicate pustular psoriasis management 2, 1
• Generalized pustular psoriasis typically requires systemic therapy rather than topical treatments alone 1, 4

Alternative Topical Treatment Options

• Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are safer alternatives for sensitive areas like the face and intertriginous regions 2, 1
• Calcineurin inhibitors are especially helpful on thinner skin and can be used as steroid-sparing agents for prolonged use (≥4 weeks) 2
• Vitamin D analogs (calcipotriene, calcitriol) can be considered for localized pustular psoriasis 1, 5
• Combination therapy using topical corticosteroids with other agents (vitamin D analogs, retinoids, etc.) may provide enhanced efficacy while reducing steroid exposure 4, 5

Treatment Algorithm for Pustular Psoriasis

1. For localized pustular psoriasis (palms and soles):

   • Start with moderate potency topical corticosteroids for rapid control 1
   • Use for short duration (2-4 weeks) to minimize adverse effects 2
   • Gradually taper frequency of application after clinical improvement 2

2. For sensitive areas (face, intertriginous regions):

   • Use topical calcineurin inhibitors instead of steroids 2, 1
   • Consider tacrolimus 0.1% for up to 8 weeks for inverse psoriasis 2

3. For maintenance therapy:

   • Transition to intermittent use of the least potent effective steroid 2
   • Consider steroid-sparing agents like vitamin D analogs or combination therapy 4, 5

4. For generalized pustular psoriasis:

   • Topical steroids alone are insufficient; systemic therapy is typically required 1, 6
   • In pregnancy-associated pustular psoriasis, narrowband UVB with limited topical steroids may be considered 7

Monitoring and Precautions

• Regular clinical examinations are essential for patients on long-term topical steroid therapy 2
• Monitor for signs of skin atrophy, striae, and other local adverse effects 2
• Be alert for signs of rebound or worsening upon steroid discontinuation 2, 1
• Avoid unsupervised use of potent topical steroids 2
• Limit application to approximately 400g of topical agent per week for an average-sized adult when treating extensive areas 2