Prednisone Should Be Avoided in Psoriasis Treatment
Systemic corticosteroids like prednisone are contraindicated in psoriasis because they can precipitate severe, potentially life-threatening flares including generalized pustular psoriasis upon withdrawal. 1, 2
Why Prednisone Is Dangerous in Psoriasis
Systemic corticosteroids create severe rebound phenomena when discontinued, causing the disease to worsen dramatically beyond its baseline severity. 2 This rebound effect can transform stable plaque psoriasis into generalized pustular psoriasis, a medical emergency requiring hospitalization. 2
The American College of Rheumatology explicitly states that systemic corticosteroids are absolutely contraindicated as primary therapy in generalized pustular psoriasis, as they can precipitate potentially life-threatening complications. 2
What Should Be Used Instead
For Limited Disease (<5% Body Surface Area)
Start with moderately potent topical corticosteroids (not oral prednisone), limiting use to no more than 100g per month with mandatory review every 4 weeks. 1 The key distinction here is topical versus systemic corticosteroids—topical preparations are first-line therapy, while systemic forms like prednisone are contraindicated. 3
- Low-potency topical corticosteroids offer little benefit for standard plaque psoriasis, so more potent topical preparations are typically needed. 3
- Vitamin D analogs (calcipotriene) can be combined with topical corticosteroids for synergistic effect and to reduce steroid exposure. 3
- Coal tar preparations (0.5-10%) are extremely safe and particularly appropriate for this patient's age group. 1
For Moderate to Severe Disease (≥5% Body Surface Area)
PUVA photochemotherapy is probably the least toxic systemic agent and generally considered the systemic treatment of first choice, with a response time of 4 weeks. 3, 1
Alternative systemic options include:
Methotrexate is especially useful for extensive chronic plaque psoriasis in a 50-year-old patient, with expected response in 2 weeks. 3, 1, 2 Maximum dose should not exceed 0.2 mg/kg body weight in patients over 70 years. 1
Cyclosporine 3-5 mg/kg/day is effective but should be used as short-term "interventional" therapy for 3-4 months only, not long-term maintenance. 1
Acitretin 0.1-1 mg/kg/day has the advantage of not being immunosuppressive, though response time is slower at 3-6 weeks. 3, 2
Critical Clinical Pitfall
Never use prednisone to "rapidly stabilize" psoriasis—it will worsen the situation upon withdrawal. 2 This is a common error where clinicians reach for systemic corticosteroids thinking they will quickly control inflammation, but this creates a dangerous cycle of dependency and rebound flaring.
The 1991 Royal College of Physicians guidelines specifically note that while combination systemic treatments are rarely needed, when they are used, extreme caution is required because toxicity is at least additive. 3 Prednisone is not listed among acceptable systemic agents for psoriasis (methotrexate, PUVA, etretinate, cyclosporin, hydroxyurea, azathioprine). 3
Monitoring Considerations
If systemic therapy becomes necessary for this 50-year-old male patient:
- Methotrexate requires: Full blood count, liver function tests, serum creatinine at baseline, then weekly monitoring initially, then every 1-2 months once stable. 3, 1
- Cyclosporine requires: Blood pressure and serum creatinine monitoring due to nephrotoxicity risk. 3
- PUVA requires: Eye examination at baseline, UV eye protection during treatment, and shielding of genitalia. 3
Bottom Line for Your Patient
For a 50-year-old male with psoriasis, start with potent topical corticosteroids combined with vitamin D analogs or coal tar. 3, 1 If disease is extensive (>5% BSA) or unresponsive to topicals, escalate to PUVA or methotrexate—never prednisone. 3, 1 The risk of precipitating life-threatening pustular psoriasis with systemic corticosteroids far outweighs any potential short-term benefit. 2