What is the recommended systemic glucocorticoid dosing regimen for an adult with an acute plaque psoriasis flare when rapid control is needed and other therapies are unavailable?

Systemic Glucocorticoids Are Generally NOT Recommended for Plaque Psoriasis Flares

Systemic glucocorticoids should be avoided in plaque psoriasis due to the risk of rebound flares upon discontinuation, lack of efficacy evidence, and availability of superior alternatives—use cyclosporine 3-5 mg/kg/day or high-potency topical corticosteroids instead. 1

Why Systemic Steroids Are Problematic

The traditional teaching against systemic glucocorticoids in psoriasis stems from well-founded concerns about disease exacerbation:

• Risk of rebound flares: European League Against Rheumatism guidelines explicitly warn that skin flares may occur with systemic steroid use, particularly upon tapering or discontinuation 1
• No proven efficacy: There is no evidence from clinical trials demonstrating efficacy of systemic glucocorticoids in psoriasis (level of evidence 4) 1
• Greater caution needed: If systemic steroids are used at all, they should be reserved for patients with severe/extensive skin involvement who are also taking concomitant DMARDs 1

Recent data suggests the flare risk may be lower than historically taught (1.42% flare rate in one cohort) 2, but this doesn't justify their use when better options exist.

The Preferred Rapid-Acting Alternative: Cyclosporine

For acute plaque psoriasis requiring rapid control, oral cyclosporine 3-5 mg/kg/day is the logical first choice due to its rapid and impressive onset of action. 1

Cyclosporine Dosing Protocol

• Initial dose: 3-5 mg/kg/day orally 1
• Duration: Short 3-4 month "interventional" course 1
• Expected response: Dramatic improvement within 2-3 weeks 1
• Monitoring: Careful attention to renal function, blood pressure, and drug interactions 1

When to Avoid Cyclosporine

Exercise caution in:

• Elderly patients 1
• Those with pre-existing renal disease 1
• Patients with hypertension 1
• Those on medications that influence cyclosporine levels 1

High-Potency Topical Corticosteroids as First-Line

For localized plaque psoriasis, ultra-high potency (class 1) topical corticosteroids achieve 58-92% efficacy rates within 2-4 weeks. 1, 3

Topical Steroid Regimen

• Potency selection: Class 1-3 (ultra-high to high potency) for thick plaques 1, 3
• Duration: Up to 4 weeks initially 1
• Application: 1-2 times daily 3
• Avoid: Face, intertriginous areas, and areas prone to atrophy (use lower potency) 1

Specific Agents with Proven Efficacy

• Halobetasol propionate ointment: 92% improvement in Physician's Global Assessment scores at 2 weeks 1
• Clobetasol foam: 68% achieved clear/almost clear skin at 2 weeks 1

Alternative Systemic Options When Cyclosporine Is Contraindicated

If cyclosporine cannot be used, consider these alternatives in order of preference:

Methotrexate (Subcutaneous Preferred)

• Advantage: Bypasses hepatic first-pass metabolism 1
• Limitation: May require dose titration, limiting rapid response 1
• Contraindications: Hepatic disease, renal disease, pregnancy planning (avoid conception for 3 months after discontinuation in males) 1
• Preferred in: Patients with clinically relevant skin involvement 1

TNF Inhibitors

• Etanercept, adalimumab, infliximab: Effective for both skin and joint manifestations 3
• Infliximab dosing: 5 mg/kg IV at weeks 0,2,6, then every 8 weeks 3
• Advantage: Can be used as bridge therapy while initiating cyclosporine 1

Acitretin

• Major limitation: Slow onset of action makes it unsuitable for acute flares requiring rapid control 1
• Absolute contraindication: Women of childbearing potential due to teratogenicity 1

If Systemic Steroids Are Absolutely Unavoidable

In rare circumstances where no other option exists (which should be exceptional):

• Dose: Lowest effective dose, typically ≤7.5 mg/day prednisone equivalent 1
• Duration: As short as possible 1
• Concurrent therapy: Always use with a DMARD (methotrexate preferred) 1
• Tapering: Extremely gradual to minimize rebound risk 1
• Monitoring: Watch closely for worsening skin disease during taper 1

Critical Clinical Pitfalls to Avoid

• Never use systemic steroids as monotherapy for plaque psoriasis—the rebound risk is unacceptable 1
• Don't delay cyclosporine in systemically ill patients with erythrodermic transformation—this is a medical urgency 1
• Avoid antibiotics with methotrexate due to drug interactions that increase toxicity 1
• Don't use acitretin for acute flares—its slow onset defeats the purpose 1
• Remember contraception counseling: Both methotrexate and acitretin require strict pregnancy prevention 1