Time to reassess messing around with steroids and psoriasis
By Warren R. Heymann, MD
March 3, 2021
Vol. 3, No. 9
You don't tug on Superman’s cape
You don't spit into the wind
You don't pull the mask off that old Lone Ranger
And you don't mess around with Jim
If the late Jim Croce was a dermatologist, he would have added the lyric that “you don’t give systemic steroids to psoriatic patients” because of the risk of inducing a pustular flare upon steroid withdrawal. Dermatology residents get indoctrinated with this dogma from day one — is it a myth?
The prevalence of psoriasis is estimated at 3.2% of adults, with an increasing incidence in children. Appropriate treatment of psoriasis is based on disease severity in the context of comorbidities and concomitant medications. (1) Even if systemic steroids are not used for psoriasis per se, their use may be indicated for co-existing maladies ranging from inflammatory bowel disease to poison ivy. Are we putting our psoriatic patients at risk by prescribing systemic steroids in these circumstances?
According to Mrowietz and Domm, only very few articles detailing the use of systemic steroids could be identified. These were mostly individual case reports or small case series from the 1950s and 1960s, considered as low-level evidence. The authors discussed a German nationwide health care insurance database revealing that systemic steroids were the most frequently prescribed drugs for psoriasis by general practitioners, internal medicine physicians, and dermatologists in 2007. Despite this fact, there was a dearth of reports of psoriasis rebound, pustular flares, erythroderma, or new-onset psoriasis. The authors concluded that a reevaluation of the treatment of psoriasis and psoriatic arthritis with systemic steroids is necessary. (2)
In an observational study of 206 adults with recent-onset psoriatic arthritis patients who were naïve to treatment, active psoriasis was observed in 174 patients (84.5%). A total of 161 steroid injections were administered (50 intra-articular and 111 intramuscular). A majority of patients were taking disease-modifying antirheumatic drugs (DMARDs) with most on methotrexate. There were no flares of psoriasis recorded as adverse events temporally related to steroid use. Overall, there was no significant change in PASI regardless of the route of administration or type or dose of steroid. Of those patients with an increase in PASI of≥2 (n=10), nine received 120 mg intramuscular methylprednisolone. (3)
In order to determine the rates and types of psoriasis flares during or within 3 months after concluding systemic corticosteroid administration in adults with a known history of psoriasis, Gregoire et al performed a retrospective cohort study assessing psoriatic patients ≥18 years old. Of 516 cohort patients, 288 (55.8%) were women, and the mean age at first psoriasis diagnosis was 49.6 years. Among 1970 patients diagnosed with psoriasis before receiving systemic corticosteroids, a 1.42% (95% CI, 0.72%-2.44%) psoriasis flare rate of any type was identified when prescribed their first course of systemic corticosteroids. Fifteen patients with flaring (93.8%) experienced worsening plaque psoriasis. One erythrodermic psoriasis flare and no pustular psoriasis flares were identified. The calculated over-all flare rate was 1.42% (95% CI, 0.72%-2.44%), with a calculated severe flare rate of 0.07% (95% CI, 0%-0.26%). (4)
Should we ignore those reports from half a century ago warning us about the hazards of systemic steroid use in psoriatic patients? Experienced dermatologists know how severe pustular psoriasis can be, especially generalized cases or in pregnant patients. Perhaps looking at triggers in documented cases of generalized pustular psoriasis (GPP) can offer some perspective. Choon et al retrospectively studied 102 patients with adult-onset GPP with a female to male ratio of 2 : 1 and mean age at onset of 40.9 years (range: 21-81 years). Acute GPP was the most common variant seen (95 cases). Common triggers were systemic steroids (45 cases), pregnancy (17 cases), and upper respiratory tract infections (16 cases). A positive family history of psoriasis and GPP was present in 29% and 11%, respectively. Comorbidities included obesity (42.9%), hypertension (25.7%), hyperlipidemia (25.7%), and diabetes mellitus (23.7%). (5)
What we need to understand is why occasional psoriatic patients flare when exposed to steroids. Is it genetics? Comorbidities? Interactions with other medications?
For the vast majority of patients, however, if systemic steroids are necessary in patients with psoriasis or psoriatic arthritis, they should not be withheld based on fear of inducing a severe flare based on prior dogma. In Jim Croce’s You Don’t Mess Around with Jim, Slim changed the prevailing dictums. I concur with the conclusion by Gregoire et al: “This study’s results suggest that psoriasis flare rates for patients taking or finishing systemic corticosteroid courses is very low and predominantly associated with mild flaring. While we are not advocating systemic steroids to treat psoriasis, we challenge the notion that steroids induce severe psoriasis flares at significant rates in a general psoriasis population. Strict avoidance of systemic corticosteroids in patients with psoriasis may be unnecessary” (4)
Point to Remember: If systemic steroids are deemed necessary for patients with psoriasis or psoriatic arthritis, they should not be withheld based on the fear of inducing a pustular or erythrodermic flare. The risk for these severe adverse events is far less likely than has been assumed by generations of dermatologists.
Our expert’s viewpoint
Erik J. Stratman, MD
Clinical Professor of Dermatology, University of Wisconsin-Madison
Chair, Department of Dermatology, Marshfield Clinic
We are living in the golden age of psoriasis therapy. Now, more than ever, new drugs exist that effectively treat this disease affecting millions of patients worldwide. Conclusions from this research do not suggest that systemic steroids should climb higher on the psoriasis therapeutic ladder. Instead, I hope this work will stimulate in the readers’ minds the importance of remaining curious and willing to objectively question certain dogma that seems inconsistent with what is experienced in clinical practice.
The origin of the word “doctor” comes from the Latin word “docere,” meaning “to teach.” Many great teachers impart lessons along our journey to taking care of patients with skin disease. Although many lessons are taught to us with great conviction and certainty, some of those lessons are simply not true. There will be great value in the clinical research ahead that seeks to answer “Why do we do what we do, is it all necessary, and are the ways I was taught to view this or do this consistent with what I experience in practice?” From exploring the necessity of certain drug lab monitoring strategies to challenging the fears that may have been instilled in us to ensure psoriasis patients avoid systemic steroids, the quality of care can be lifted by those who remain curious. Tempering the absoluteness of our lessons with humility and lighting the fire of curiosity are two of the greatest gifts a teacher can give.
Armstrong AW, Aldredge L, Yamauchi PS. Managing Patients With Psoriasis in the Busy Clinic: Practical Tips for Health Care Practitioners. J Cutan Med Surg. 2016 May;20(3):196-206. doi: 10.1177/1203475415623508. Epub 2015 Dec 28. PMID: 26712930; PMCID: PMC4834511.
Mrowietz U, Domm S. Systemic steroids in the treatment of psoriasis: what is fact, what is fiction? J Eur Acad Dermatol Venereol. 2013 Aug;27(8):1022-5. doi: 10.1111/j.1468-3083.2012.04656.x. Epub 2012 Jul 25. PMID: 22830601.
Coates LC, Helliwell PS. Psoriasis flare with corticosteroid use in psoriatic arthritis. Br J Dermatol. 2016 Jan;174(1):219-21. doi: 10.1111/bjd.14061. Epub 2015 Nov 22. PMID: 26255625.
Gregoire ARF, DeRuyter BK, Stratman EJ. Psoriasis Flares Following Systemic Glucocorticoid Exposure in Patients With a History of Psoriasis. JAMA Dermatol. 2021 Feb 1;157(2):198-201. doi: 10.1001/jamadermatol.2020.4219. PMID: 33206132; PMCID: PMC7675213.
Choon SE, Lai NM, Mohammad NA, Nanu NM, Tey KE, Chew SF. Clinical profile, morbidity, and outcome of adult-onset generalized pustular psoriasis: analysis of 102 cases seen in a tertiary hospital in Johor, Malaysia. Int J Dermatol. 2014 Jun;53(6):676-84. doi: 10.1111/ijd.12070. Epub 2013 Aug 22. PMID: 23967807.
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