Are steroids, such as prednisone (corticosteroid), given for chronic regional pain syndrome (CRPS) and when?

Corticosteroids for Complex Regional Pain Syndrome (CRPS)

Yes, oral corticosteroids (prednisone or prednisolone) should be given for acute CRPS, initiated as early as possible after diagnosis, typically starting at 30-60 mg daily with a taper over 2-4 weeks. 1, 2

When to Initiate Steroids

Start corticosteroids immediately upon diagnosis of acute CRPS (symptoms <1 year duration), particularly when multiple joints are involved. 1, 3

Optimal Timing

• Earlier treatment correlates with better range of motion recovery - initiate within the first few months of symptom onset when possible 1
• Treatment has been studied in patients with symptom duration averaging 80 days, with significant benefit 1
• The acute phase represents the window for potentially disease-modifying and curative treatment 3

Dosing Regimen

Initial Dose

• Start with 30-60 mg daily of prednisone/prednisolone 1, 2, 4
• 30 mg daily has been shown effective in controlling symptoms, making higher doses potentially unnecessary 4
• One commonly used protocol: 60 mg daily for acute cases with multijoint involvement 1

Taper Schedule

Use a 2-4 week taper regimen: 1, 2, 4

• Typical 3-week protocol: Start 30 mg daily, taper by 5 mg every 3 days until discontinuation 2
• Alternative 4-week protocol: 60 mg with gradual taper over 28 days 1
• Short-term treatment (1-2 weeks) has also shown effectiveness 4

Expected Outcomes

Symptom Resolution

Approximately 50% of patients achieve complete pain resolution, with another 50% experiencing significant pain reduction allowing functional use 1

Specific Improvements

• All CRPS symptoms and signs decrease significantly (p<0.001): 1, 2

  • Morning stiffness
  • Cold intolerance
  • Hyperesthesia
  • Abnormal sweating
  • Cyanosis
  • Shoulder pain
  • Numbness

• Pain scores (VAS at rest and activity) improve significantly 2

• Grip strength, pinch strength, and range of motion all show significant improvement 2

• Functional ability (Q-DASH scores) and quality of life (SF-36) improve significantly 2

• Benefits persist at 6-month and 12-month follow-up 5

Safety Profile

Side effects are minimal with short-course therapy: 4, 5

• Only 0-30% of patients experience minor side effects 4
• Low risk profile with short-term use 5
• No serious adverse events reported in reviewed studies 4

Clinical Caveats

Diagnostic Requirements

• Confirm diagnosis using Budapest criteria before initiating treatment 3
• Consider bone scan for confirmation when clinical diagnosis is uncertain 3

Treatment Failures

• Range of motion deficits may persist in approximately 50% of patients, though most (17/19) still report functional ROM recovery 1
• Patients without improvement after the initial course may require multimodal treatment including sympathetic blocks 6, 7

Common Pitfall

The major clinical failure is not offering this treatment at all - despite growing evidence and guideline support, corticosteroids remain underutilized for acute CRPS, potentially resulting in long-term pain, joint contracture, and permanent disability 3

Integration with Other Therapies

• Corticosteroids should be part of a multimodal approach when used 7
• Consider sympathetic blockade (stellate ganglion or lumbar sympathetic block) for patients showing consistent improvement with successive blocks 7
• Sympathetic blocks are recommended specifically when there is increasing duration of pain relief with each successive block 7