Although dermatologists are taught to avoid systemic steroids because of psoriasis flare risk, the rates and severity of flaring are "very low," researchers suggest. "There is a commonly held belief in dermatology education propagated over decades that psoriasis patients should avoid systemic glucocorticoids because (they) will trigger severe flares of psoriasis at significant rates, including dangerous pustular or erythrodermic flares," Dr. Erik Stratman of Marshfield Clinic Health System in Wisconsin told Reuters Health by email. "Yet, in our systemwide dermatology practice, we managed hundreds of psoriasis patients who had been prescribed systemic glucocorticoids, either for their skin disease at some point or for another medical condition, and we rarely, if ever, noted any type of flaring during or after tapering these systemic steroids," he said. "This got my team thinking, 'is the danger of steroid-induced flaring really true?'" As reported in JAMA Dermatology, the team analyzed medical records of adults with psoriasis and exposure to at least one systemic corticosteroid from about 2012 to 2018. The primary outcome was the rate of psoriasis flares during or within three months of discontinuation of the first course of systemic corticosteroids. Five hundred and sixteen eligible patients were included (out of 1,970 with psoriasis who received systemic steroids). 56% were women; the mean age at first psoriasis diagnosis was 50; the mean age at first systemic steroid prescription was 61; and 11.4% were receiving concurrent systemic psoriasis therapies. The median corticosteroid dose in those with and without psoriasis flares was 40 mg (25%, 20 mg; 75%, 40 mg). Of 43 patients with psoriasis encounters during the corticosteroid period, 14 (5.8%) experienced flares. Other medications reported to flare psoriasis were identified in patients with flaring, including six (37.5%) taking beta-blockers, one (6.25%) taking hydroxychloroquine, and one (6.25%) taking quinacrine. Overall, a 1.42% psoriasis flare rate of any type was seen when patients were prescribed their first course of systemic corticosteroids. Further stratification revealed only one severe flare (erythroderma) and no pustular psoriasis flares. The authors conclude, "Our results suggest that systemic steroids may be much less likely to trigger severe with psoriasis than what is traditionally taught in dermatology." Dr. Stratman said, "This has been practice-changing for us, because it shifts the way we view the danger of systemic steroids in psoriasis patients. While we do not advocate treating psoriasis with systemic glucocorticoids, it has certainly softened our worry and counseling about severe flares in those who are taking or tapering off of chronic steroids for one reason or another." "I am hopeful that any psoriasis guideline that expressly states that psoriasis patients should avoid systemic steroids due to the risk of severe flaring will look at this data, challenge the dogma, and temper their language," he concluded. Dr. Suzanne Friedler, a clinical instructor at Mount Sinai Medical Center in New York City, commented in an email to Reuters Health, "Abrupt discontinuation of systemic steroids has been known to trigger psoriatic flares. However, there are many factors that can affect this, including the strength of the dose, the length of the steroid course and the protocol for tapering off the systemic medication." "The use of concurrent treatments for psoriasis such as topical corticosteroids, retinoids, biologics and other systemic treatments will reduce a patient's likelihood of flaring following systemic steroid exposure," she said. "In this study, rates of psoriasis flares were low, less than 1.5% of the population that was studied," she noted. "It is possible that this reflects the current advances in treating psoriasis in general, however only about 11.4% of patients in the study were on concurrent treatments. Because this was a retrospective chart review, it is possible that both flares and concurrent treatments were underreported." "Nevertheless," she added, "it is encouraging to know that systemic steroids can be used in patients with a history of psoriasis without fearing a flare." —Marilynn Larkin Source
