D ermatologists have been recommended—through textbooks and treatment guidelines—to avoid systemic steroids in patients with psoriasis because of the risk for triggering severe psoriasis flares, explains Erik Stratman, MD. “These recommendations are based on what I consider to be misinterpreted case series from the 1950s and 60s in which most patients with severe pustular psoriasis received systemic steroids prior to a flare, leading to the conclusion that systemic steroids are associated with severe flares,” he notes. “But these case series didn’t consider how many patients with psoriasis received systemic steroids but didn’t have severe flares.”
With more recent research finding a lack of such flares and personal experience treating many patients with psoriasis who were prescribed systemic steroids—including acute burst and taper steroid courses, as well as chronic stable courses and slowly tapering chronic steroid courses by other physician specialists outside of dermatology and typically for other conditions without incident— Dr. Stratman and colleagues investigated nearly 2,000 adult patients (aged 18 or older at time of psoriasis diagnosis) in their health system with an established diagnosis of psoriasis and exposure to at least one systemic corticosteroid between October 31, 2012 and July 1, 2018. “There are many reasons why a patient with psoriasis may deserve systemic steroid treatment but may not get it because of the above-mentioned teachings and recommendations,” Dr. Stratman adds.
Looking for Steroid-Associated Psoriasis Flares Via Chart Review
For the retrospective study, published in JAMA Dermatology, the researchers sampled and manually abstracted more than 500 charts, including all patients with psoriasis who also had dermatologist visits during or within 3 months of completing systemic steroid therapy; among these 516 patients, 55.8% were women, and the mean age at first psoriasis diagnosis was 49.6. “We oversampled this group with the thought that patients experiencing severe psoriasis flares would most likely visit their dermatologist to manage their skin disease,” explains Dr. Stratman. “We also abstracted the charts of a random sampling of patients with psoriasis who received systemic steroids but did not visit their dermatologist during the period of steroid exposure, to ensure we didn’t miss a flare that escaped dermatology care.”
The study team also assessed rates of specific psoriasis flare types, including pustular, erythrodermic, and worsening plaque stage psoriasis. Patients younger than 18, those with psoriatic arthritis, and those receiving only topical, intraarticular, or intrabursal corticosteroids were excluded from the study.
Low Rates of Psoriasis Flares
“There was a very low rate of psoriasis flares in patients with psoriasis who received systemic steroids,” notes Dr. Stratman. Indeed, among 1,970 patients with a diagnosis of psoriasis before receiving systemic corticosteroids, the rate for psoriasis flare of any type was 1.42% (95% coifnfidence interval, 0.72-2.44) when they were prescribed a first course of these agents. Other key findings, according to Dr. Stratman, include:
- “The vast majority of documented psoriasis flares occurring in patients with psoriasis who received systemic steroids were mild disease flares (worsening chronic plaque disease), not severe disease flares (Table). › Most psoriasis flares in patients who received systemic steroids were associated with other factors that may explain them (eg, documented strep throat infections, new betablocker therapy).
- The rates of severe psoriasis flares, defined as pustular psoriasis and erythroderma psoriasis, were extremely low (only one documented erythrodermic psoriasis flare and zero pustular psoriasis flares; Table) and were no higher than rates expected in the general psoriasis population.
- The low rate of overall psoriasis flares likely is no different than the natural ebbs and flows of disease flaring that occur with psoriasis independent of systemic steroid therapy.
- Exposure to short-term or long-term systemic steroids in this upper Midwestern rural patient population did not result in significant rates of patients experiencing severe flares.”
Although Dr. Stratman does not advocate that dermatologists elevate systemic steroids on the therapeutic ladder of psoriasis treatment, he notes that the current study data indicate that systemic steroid exposures do not appear to significantly increase psoriasis flare rates. He adds, however, that the study occurred in a rural, Midwestern, predominantly White patient population and that repeating the study in a more diverse patient population would be additive and help solidify the findings.