Oral Corticosteroids for Psoriatic Arthritis: Not Recommended
Oral corticosteroids should generally be avoided as monotherapy for psoriatic arthritis due to lack of clinical trial data supporting their efficacy and the significant risk of psoriasis flare-ups during or after tapering. 1
Why Systemic Corticosteroids Are Not Recommended
Lack of Evidence and Safety Concerns
No recommendation can be given regarding efficacy and side effect profiles of systemic corticosteroids because clinical trial data are not available for psoriatic arthritis. 1
Monotherapy with systemic corticosteroids should be avoided in psoriasis because skin disease can flare during or after taper. 1
Half of dermatologists (50%) and a fourth of rheumatologists (29%) have observed at least one psoriasis flare-up following treatment with oral corticosteroids. 2
The risk of disease deterioration after dose reduction or withdrawal is well-documented, with potential for pustular or erythrodermic flares. 3
Limited Acceptable Uses
Intra-articular Injections Only
Intra-articular glucocorticoid injections may be given judiciously to treat persistently inflamed joints, if care is taken to avoid injection through psoriatic plaques. 1, 4
Local corticosteroid injections can be administered directly into inflamed joints for additional symptom control in mild disease. 5
Injections to any one joint should be repeated with caution according to clinical judgment. 1
Rare Exception: Adjunctive Low-Dose Therapy
One case report suggests that monitored use of low-dose prednisolone (10 mg on alternate days) combined with methotrexate may control severe symptoms when DMARDs alone fail, but this should not be considered standard practice. 6
This approach is discouraged as monotherapy and should only be considered when biologics are unavailable or unaffordable. 6
Recommended Treatment Algorithm Instead
For Mild Disease
- Start with NSAIDs for joint symptom control. 1, 4
- Add intra-articular glucocorticoid injections for persistently inflamed joints. 1, 4
For Moderate to Severe Disease
Initiate DMARDs rapidly: sulfasalazine or leflunomide (Level A evidence), or methotrexate when significant skin involvement exists (Level B evidence). 1, 4
Progress to TNF inhibitors (etanercept, infliximab, adalimumab) after failing at least one DMARD trial of more than 3 months with more than 2 months at standard target dose. 4, 7
For Poor Prognosis Factors
- Consider TNF inhibitors earlier if polyarticular disease, elevated inflammatory markers, existing joint damage, or diminished quality of life are present. 4, 7
Critical Clinical Pitfall
The widespread prescription of systemic corticosteroids for psoriasis by general practitioners and internal medicine physicians contradicts dermatological guidelines and poses significant risk of disease exacerbation. 3 This practice should be actively discouraged in favor of evidence-based DMARD and biologic therapies that prevent structural joint damage and do not risk psoriasis flares. 8