What is the recommended tapering schedule for cyclosporin (cyclosporine) in patients with pustular psoriasis?

Cyclosporin Tapering in Pustular Psoriasis

For pustular psoriasis, taper cyclosporin by reducing the dose by 1 mg/kg/day weekly after achieving disease control, rather than stopping abruptly, as this approach delays relapse by approximately 4 days while maintaining safety. 1

Initial Treatment Phase

• Start cyclosporin at 5 mg/kg/day divided into two doses for rapid control of pustular psoriasis, as this severe variant requires aggressive initial management 1, 2
• Continue treatment for 12-16 weeks or until achieving ≥90% clearance of pustular lesions 1
• For generalized pustular psoriasis, lower doses of 1-2 mg/kg/day may achieve clearance within 2-4 weeks, though this is based on pediatric data 3

Recommended Tapering Protocol

Once disease control is achieved, reduce cyclosporin by 1 mg/kg/day each week until complete cessation. 1 This stepwise approach is superior to abrupt discontinuation based on evidence from 365 patients with severe psoriasis:

• Gradual taper: Median time to relapse of 113 days 1
• Abrupt cessation: Median time to relapse of 109 days 1, 4
• The difference is statistically significant (P = 0.038) though clinically modest 4

Alternative Tapering Strategy

For patients requiring longer-term control, consider maintenance dosing at 3.0 mg/kg/day after initial clearance rather than complete cessation 1:

• At this maintenance dose, 58% of patients maintained improvement through 24 weeks 1
• Laboratory abnormalities from the induction phase tend to normalize at lower maintenance doses 1
• This approach reduces cumulative drug exposure compared to continuous high-dose therapy 1, 2

Critical Monitoring During Taper

Monitor serum creatinine and blood pressure every 2 weeks during tapering 1, 2:

• If serum creatinine increases >30% above baseline, reduce dose by 25-50% immediately 5
• If blood pressure becomes uncontrolled, slow the taper and consider calcium channel blockers (preferably isradipine) 2, 5
• Discontinue cyclosporin if renal function does not improve with dose reduction 5

Transition Strategy to Prevent Relapse

Initiate alternative therapy before completing cyclosporin taper to maintain disease control 1, 6:

• Starting topical anthralin (dithranol) during taper significantly reduces relapse rates compared to cyclosporin cessation alone 6
• The combination of tapering plus topical therapy shows lower relapse incidence than abrupt cessation with topical therapy 6, 4
• For pustular psoriasis specifically, have a biologic or alternative systemic agent ready to start as cyclosporin is withdrawn 2

Common Pitfalls to Avoid

Never stop cyclosporin abruptly in pustular psoriasis, as this can precipitate rebound with erythrodermic or generalized pustular flares 1:

• Systemic corticosteroids should NOT be used to manage rebound, as their withdrawal can worsen pustular disease 1
• Avoid simultaneous use of NB-UVB phototherapy with cyclosporin due to photocarcinogenesis risk 1
• Do not use thiazide or potassium-sparing diuretics for hypertension management during taper 2

Expected Outcomes

Approximately 30% of patients remain relapse-free 6 months after cyclosporin cessation with proper tapering 4:

• Median time to relapse is approximately 3-4 months after stopping therapy 1
• Patients requiring retreatment respond similarly to initial therapy, with 76% achieving PASI 75 in second courses 4
• Short intermittent courses (2-12 weeks) are well tolerated with only 8% discontinuing due to adverse effects 1