Oral steroids for psoriasis

Debunking Psoriasis Myths: Do Systemic Steroids Used in Psoriasis Patients Cause Pustular Psoriasis?

Myth: Systemic steroids cause pustular psoriasis

The advent of biologic therapy for psoriasis has changed the landscape of treatments offered to patients. Nevertheless, systemic therapies still play an important role, according to the American Academy of Dermatology psoriasis treatment guidelines, due to their oral route of administration and low cost compared to biologics. They are options for patients with moderate to severe psoriasis that is unresponsive to topical therapies or phototherapy. However, many dermatologists feel that it is inappropriate to prescribe oral steroids to psoriasis patients due to the risk for steroid-induced conversion to pustular psoriasis, the long-term side effects of steroids, and deterioration of psoriasis after withdrawal of steroids.

Pustular psoriasis appears clinically as white pustules (blisters of noninfectious pus) surrounded by red skin. The pus consists of white blood cells. There are a number of triggers in addition to systemic steroids, such as internal medications, irritating topical agents, overexposure to UV light, and pregnancy. Stopping an oral steroid abruptly can cause serious disease flares, fatigue, and joint pain.

Westphal et al described the case of a 70-year-old woman with palmoplantar psoriasis who was diagnosed with acute generalized exanthematous pustulosis that was treated with corticotherapy by injection and then oral prednisone. She experienced improvement, but her symptoms worsened when she was in the process of reducing the prednisone dose. The dose was increased again, and the same worsening of symptoms was experienced when the dose was reduced. After completely abandoning oral steroid therapy, she developed a severe case of generalized pustular psoriasis that was treated with acitretin. This case illustrates the dangerous consequences of abruptly discontinuing oral steroids.

However, dermatologists may be using oral steroids for psoriasis more often than treatment guidelines suggest. In 2014, Al-Dabagh et al evaluated how frequently systemic corticosteroids are prescribed for psoriasis in the United States. The researchers reported, “Despite the absence or discouragement of systemic corticosteroids in psoriasis management guidelines, systemic corticosteroids are among the most common systemic treatments used for psoriasis.” They found that systemic corticosteroids were prescribed at 650,000 of 21,020,000 psoriasis visits, of which 93% were visits to dermatologists. Prednisone was the most commonly prescribed systemic corticosteroid, followed by methylprednisolone and dexamethasone. To prevent rebound flares, systemic corticosteroids were prescribed with a topical corticosteroid in 45% of the visits in patients with psoriasis as the sole diagnosis. They concluded, “The striking contrast between the guidelines for psoriasis management and actual practice suggests that there is an acute need to better understand the use of systemic corticosteroids for psoriasis.”

The benefits of systemic corticosteroids versus the frequency of adverse reactions should be weighed by dermatologists and patients to make evidence-based decisions about treatment. Patients should take oral steroids exactly as prescribed by physicians.

Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol. 2009;61:451-485.

Westphal DC, Schettini APM, de Souza PP, et al. Generalized pustular psoriasis induced by systemic steroid dose reduction. An Bras Dermatol. 2016;91:664-666.

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PMC

Discussion

PsA has traditionally been viewed as a disease with benign prognosis. However, radiographic evidence indicates that the disease is more progressive and destructive than previously thought. Inflammatory eye involvement too has been observed in one-third PsA patients. About 20% of patients with PsA develop severe disability and nearly 50% will develop erosive arthritis in the first 2 years itself. Our clinical experience too suggests that patients with initial mild PsA often develop severe deforming disease later. Characteristic radiographic features of PsA include reduced joint space (as seen in our patient), joint erosions, periarticular and shaft periostitis, osteolysis, spondylitis, spur formation, and ankylosis varying with its severity. An early and effective intervention is thus imperative before significant permanent damage to a joint occurs. Treatment of psoriatic arthritis with NSAIDs has generally been similar to that of other types of inflammatory arthritis despite concerns that NSAIDs may exacerbate the associated skin disease. PsA unresponsive to NSAIDs is usually managed with DMARDs such as methotrexate, sulfasalazine, gold salts, cyclosporine, or leflunamide. However, potential differences in their efficacy and toxicity need be evaluated before using these drugs. For instance, in a comparative study, the difference in efficacy was not significant for three drugs (methotrexate, sulfasalzine, and parenteral gold) in PsA and rheumatoid arthritis while the PsA patients required treatment for longer period and toxicity was more frequent among them. Further, adverse effects from drug – drug interaction may occur more often when methotrexate is combined with NSAIDs. Also, there is very little data or radiographic evidence that DMARDs have lessened joint pain and inflammation or limited the progression of joint damage in PsA. Clinical and radiographic progression was observed significantly reduced in the groups treated with etanercept, adalimumab, or infliximab with or without adding methotrexate at the baseline level suggesting that biologic response modifiers may have better efficacy without toxicities versus conventional therapies. However, these are prohibitively expensive and patients with mild joint symptoms or only a few involved joints may not need treatment with biologics. Although corticosteroids, systemic or intra-articular, have been used in mutilating PsA for rescue, there are concerns over worsening of skin disease, particularly after withdrawal of relatively short courses, and that the corticosteroids may cause the skin disease to become resistant to other therapies. Other workers too have suggested that the use of corticosteroids is perhaps a risk factor for the development of PsA in a psoriasis patient. Our patient showed no significant improvement in PsA with the NSAIDs given alone or in combination with methotrexate. In fact, it was frustrating for the patient and his family members as he was not getting any relief. His symptoms decreased in the first week itself and he became asymptomatic, even without NSAIDs, as the treatment with low dose prednisolone and methotrexate progressed. Methotrexate combined with betamethasone had cleared the lesions faster and with a longer remission period compared with methotrexate alone in a randomized study. However, this study did not evaluate patients having psoriatic arthritis. With their well-recognized anti-inflammatory, anti-proliferative, and immunosuppressive activities corticosteroids perhaps act at all levels of inflammatory response in synovium/PsA/enthesitis just as in psoriatic lesions and prevent osteoclastogenesis/bony erosions. However, corticosteroids at best be considered as temporizing agents to assist in bringing the inflammation of PsA under control while an alternative therapy, which may have a more gradual onset of action, will provide long lasting control sparing the patients from the potential drug toxicity. We feel that monitored use of corticosteroids, even in low doses, combined with DMARDs may be a good therapeutic option in the early stage of the PsA rather than as ‘steroid rescue’ later. This will achieve an early symptomatic relief in PsA, prevent joint damage in the long run, and maintain good functional capacity and quality of life especially when the cost or availability of biologics precludes their use. However, more controlled studies are needed before making any recommendations. The use of systemic corticosteroids as mono-therapy, however, should be discouraged.

What is new?

Early addition of low dose systemic steroids to methotrexate in severe psoriatic arthritis prevents significant joint damage and maintains long-term functional capacity and quality of life.

Psoriasis is a common skin condition with systemic considerations. The skin component is variable among patients, but the most common type, plaque psoriasis, consists of raised lesions covered with a variable amount of silvery scales most commonly seen on the elbows, knees, scalp, and trunk. Other types of psoriasis are guttate, inverse, pustular, scalp, erythrodermic, and psoriatic inflammatory arthritis.

Guttate psoriasis consists of drop-like lesions, usually with a sudden onset and commonly seen after a streptococcal pharyngitis infection and more commonly seen in children and young adults. This type may come and go and does not necessary mean that a patient will develop ongoing, chronic plaque-type psoriasis.

Inverse psoriasis is a type of psoriasis where the scaly plaques develop in skin fold areas like the axillae, groin and buttock creases and the folds under the breasts. Because of the heat and skin-on-skin friction at these sites, the scales tend to be rubbed off and all that remains is shiny red smooth areas that look like scalded skin.

Erythrodermic psoriasis very often occurs after a stressful event in the body as a whole, such as an infection, fever, or other significant illness. Patients with this type of psoriasis report that the skin becomes bright red all over, with or without significant scaling. Nail changes including loss of nails may be seen with this type of psoriasis. Fevers and chills may accompany this form of psoriasis. With significant involvement of the skin, patients with erythrodermic psoriasis may need to be treated in a burn unit because of loss of fluid, electrolytes, protein, and disruption of normal body hemostasis functions.

Three types of pustular psoriasis exist: von Zumbusch, palmoplantar pustulosis, and acropustulosis (acrodermatitis continua of Hallopeau). Pustular psoriasis of von Zumbusch appears as a distinctive acute form of psoriasis that develops after a significant fever and manifests itself with crops of sterile pustules over the trunk and extremities. These pustules develop in clusters on top of bright red skin. These clusters of pustules usually coalesce into larger areas as the disease progresses. Patients tend to have waxing and waning of the fever with pustules developing throughout the flare. The face, as with most types of psoriasis, is usually spared. Palmoplantar pustulosis develops as multiple sterile pustules on the palms and soles that eventually turn brown, peel and crust over with repeated episodes occurring. Smoking can aggravate all types of psoriasis, but palmoplantar pustulosis is particularly common among smokers. Acropustulosis is manifested by skin lesions at the end of the fingers and toes starting after an injury to the skin or infection. These lesions can be quite painful and may cause deformity of the nails. With severe causes the inflammation can be severe enough to cause boney changes.

Some patients will develop only scalp involvement and this type of psoriasis can often be misdiagnosed as seborrhea (cradle cap) or tinea (fungal/ringworm). Generally there is a family history of psoriasis that can help with the diagnosis, and the scale of scalp psoriasis is usually more white/silvery than the waxy, off-white/yellowish scale of seborrhea.

Because psoriasis is a systemic inflammatory condition, some patients may develop psoriatic arthritis, with or without skin lesions. There is usually asymmetrical joint involvement and patients may have only a few joints (oligoarthritis) involved.

Psoriasis is often considered a skin condition, but in fact is a systemic disease resulting from a malfunction of the immune system, more specifically, over active/stimulated T-cells, a type of white blood cell involved in inflammatory activities. These overactive T cells trigger other immune responses that cause increased blood flow and inflammation in the areas of involvement with resultant increases in skin growth. The increased growth of skin cells cannot be sloughed off in a timely manner and an increased thickness (plaque) of skin develops. This cycle repeats itself (unless treatments intervene) and continued scale and plaques develop.

Psoriasis is controllable, but not curable. Many things can trigger the onset and continuation of psoriasis:

  • Bacterial and viral infections
  • Stress: emotional or frictional on the skin surface inducing new areas of psoriasis and aggravating existing plaques
  • Medications: beta-blockers, lithium, antimalarial medications, prednisone and other oral steroids
  • Injury to the skin: intentional such as with surgery, or unintentional such as a cut or scrape
  • Dry skin: may lead to scratching of the skin
  • Too little sunlight and even too much sunlight causing a sunburn
  • Alcohol
  • Nicotine: smoking and smokeless tobacco products

Patients with weakened immune systems (AIDS, cancer chemotherapy patients, and patients with autoimmune disease such as rheumatoid arthritis) may have more severe bouts of psoriasis.

Treatment of psoriasis depends on the severity of involvement (the severity may be clinically very mild, but in the eyes of the patient the ‘heart break’ of psoriasis may be significant, thus changing the therapy indicated for a particular patient) and what treatment have been employed in the past. The goal of therapy is to control the symptoms as well as to prevent infections secondary to the disruption of the normal skin barrier functions.

Three basic therapeutic options exist for the treatment of psoriasis: topical, systemic, and phototherapy. Topical treatments include moisturizers, topical steroids, non-steroid topical treatments, “peeling” agents such as salicylic acids or lactic acids, and dandruff shampoos. These products can be used individually or in combinations.

Moisturization of the skin alone may help a percentage of patients without the addition of anything else. Thicker, emollient creams are much more effective as moisturizers than lotion and in fact, some lotions, because of their water to oil ratio, may actually increase dryness of the skin (due to the evaporation of the water from the skin and the lesser amount of oils left behind.) There are many moisturizing creams on the market; the best one for you is the one you decide you are going to use…and you use it multiple times a day.

Topical ‘medicinal’ treatments include topical steroids in various formulations and strengths. The choice of formulation (cream, lotion, gel, liquid, shampoo, ointment) and strength is best determined with input from your dermatologist based on what has or has not worked in the past and what body site is being treated. Some stronger steroid products are inappropriate for your face and/or crease areas. One product’s percentage strength listed on your tube or jar does not necessary indicate a stronger or weaker product when compared to another product’s percentage strength. In other words, a betamethasone product with a strength of 0.05% is not weaker than a hydrocortisone product of 1%. There is no correlation strength to strength between two different entities.

Topical steroids are only one of many topical treatments for psoriasis. Coal tar products (OTC and Rx) have been used for years to turn down/turn off psoriasis. They can be used in the bath as a soak or direct applied to the skin and left on for a variable amount of time. Short contact therapy (SCT) with anthralin may work but has been used less and less because of more effective products, and anthralin can stain clothes and skin.

Salicylic and lactic acid containing topical products are used to reduce the thickness of scales and are often combined in a compounded product with topical steroids and/or emollient OTC moisturizer creams.

Vitamin-D analog containing ointments (calcipotriene and calcitriol) can be used as stand-along products or in combination with topical steroids (pre-made ready to use by the manufacturer or as individual products applied at different times of the day/week). These products tend to take longer for results to be noticed by the patient, so a minimum trial period of 2-3 months may be necessary before changing to something else.

Tazarotene is a topical retinoid that is used both for acne and psoriasis. This product may cause irritation and dryness of the skin. Combining it with topical steroids and/or emollient moisturizers may reduce the irritation.

Systemic therapies include oral and injectable products. Methotrexate is one of the older oral products used for psoriasis. It works by inhibiting an enzyme involved in rapid cell growth. Methotrexate can be taken orally or by injection and patients using this medication need to be monitored regularly with blood work and possibly a liver biopsy, especially with accumulated doses over months/years of therapy. Avoidance of alcohol is required while on this medicine. Acitretin is another oral medicine for the treatment of psoriasis. This medicine needs regular monitoring, too, both for blood counts, liver enzymes, and triglyceride and cholesterol levels. Avoidance in pregnant and pregnant-potential-aged patients is a must as this drug causes severe birth defects. Significant sensitivity to UV exposure may also be a problem with this medication.

In some psoriasis patients, because their activity is triggered by infections, chronic antibiotic use has been utilized as an adjunctive therapy.

Cyclosporine which works to slow the growth of skin cells by suppressing the immune system directly has been used for psoriasis treatment, but is limited to a maximum of 9-12 months. Regular monitoring of therapy is required. This is also true for the use of mycophenolate mofetil (CellCept®).

The newer “biological” injectable medicines are being used more and more often for the treatment of psoriasis. There are several to choose from and in consultation with your dermatologist, the most appropriate product for you and your condition can be used. These include: adalimumab (Humira®), etanercept (Enbrel®), infliximab (Remicade®), and ustekinumab (Stelara®). Some of these products are self-administered and some require SQ or IV administration by your physician or staff.

Phototherapy is a treatment for psoriasis that involves careful exposure of your skin to ultraviolet light. Both UVA and UVB therapies are used and both require monitoring and care when using. Phototherapy may be used alone or in combination with topical and/or oral therapies. UVA therapy as a stand-alone treatment is not effective for psoriasis (one of the reasons why a trip to the tanning booth is not appropriate for psoriasis treatment), but combining it with oral (or bath-applied) psoralens which makes the skin more sensitive to UVA light, is used and commonly called PUVA treatment. This type of treatment is undertaken at your physician’s office or a treatment center. UVB light therapy can be used at home with purchased UVB light ‘box’ and monitored with regular interaction with your dermatologist or administered at your dermatologist’s office.

Potential complications from psoriasis include arthritis, pain, itchiness which can sometimes be severe and may lead to secondary skin infections, side effects from your treatment medicines, psychiatric or depression episodes because of your condition and even skin cancer from UV treatments. All of these can be discussed, and very often controlled, with ongoing evaluations and discussions with your dermatologist.

Some home-use tips include the use of non-drying, non-harsh soaps (sometimes anti-bacterial, deodorant soaps may be too drying for your skin) and when bathing, use cleansers in “strategic” areas only…armpits, groin, hands, and face and where you see dirt. It is not always necessary to lather the entire body every time you bathe. Regular, emollient cream/moisturizer applications to the trunk and extremities—more frequently in the often times drier winter months than the more humid summer months will aid in the prevention of dry skin with the subsequent tendency to scratch and potential flare your psoriasis. Mild UV exposure (even on a cloudy day) may help, but be careful not to sunburn as this can actually flare some psoriasis patients. Anti-stress and relaxation techniques may be a part of overall general well-being and may actually lessen your potential to flare.

For more information:

The National Psoriasis Foundation
1.800.723.9166

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The medical information provided in this site is for educational purposes only and is the property of the American Osteopathic College of Dermatology. It is not intended nor implied to be a substitute for professional medical advice and shall not create a physician – patient relationship. If you have a specific question or concern about a skin lesion or disease, please consult a dermatologist. Any use, re-creation, dissemination, forwarding or copying of this information is strictly prohibited unless expressed written permission is given by the American Osteopathic College of Dermatology.

Prednisone: My Best Friend and My Worst Enemy

I called my rheumatologist the other day (yet again). My next infusion isn’t for another few weeks and I was in the middle of a serious flare. Swelling joints, aching back, and the worst of all, never-ending fatigue. I’ll be completely honest and tell you, I called my doctor, hoping against hope, that I would be prescribed real, actual pain medicine. My current prescription NSAIDS do nothing to help my pain. I might as well be popping Tic Tacs. Relief from ice and heat are only temporary. Tylenol is a joke. What did I get? Steroids, my old friend. We meet again.

My love-hate relationship with steroids began quite some time ago when I was having frequent and severe asthma attacks. Of course, I was prescribed steroids, both pill form, and inhaled. Within 2 weeks, I gained nearly 40 pounds and my temper caused anyone within a 10 mile radius to run for cover from my wrath. Sure, they worked as prescribed, I could breathe again, but at what cost?

My best friend

The story today is no different. Those lovely magical little pills cure a variety of what ails me. Energy? Now I have plenty to spare. Swelling joints? Gone. Everything needed to power through my life and continue on, all found in the form of several tiny, white, pills. With steroids, my body feels almost normal again. I just want to bask in the many wonderful things I can do today, that I couldn’t do yesterday, and probably won’t be able to do next week. Maybe, just for today, I will try to ignore all of those nasty little side effects that make steroids so dangerous.

My worst enemy

I’m sure you know as well as I do, with psoriatic arthritis, anything available to help, always comes at a price. The question is, how much are you willing to pay? Are you willing to put relationships in jeopardy? Are you willing to risk complications associated with steroid use, like high blood sugar or Cushing’s Syndrome? Can your grocery bill handle the entire house of food that you will want to eat when you take those magical beans? Those are some tough questions to consider. Despite the many benefits of steroids, I have found that it also comes with some seriously questionable side effects.

“Roid rage” is actually a thing

Seriously. I am normally a calm and patient person. But if steroids are involved, you better just run for cover. I know in my head that I’m angry because of the medicine, but that doesn’t always translate in the heat of the moment. You better run and hide if you cross my path as my usual laid-back persona takes on rage of Incredible Hulk proportions.

Get in my belly

If there is actually food in my house, it won’t be there for long. Bread, chips, chocolate, meat, you name it and I will convince myself that I clearly can’t live without it. I must be starving. Literally, frantically searching for another snack.

Water…..water….water

I might as well just pick up the gallon jug and pour it directly into my mouth. Forget etiquette, forget glasses, I NEED water NOW! (Must be to wash down all of those snacks.) It seems, no matter how much I drink, it never really is enough, I am constantly thirsty.

It’s getting hot in here

No amount of antiperspirant or deodorant is up to the challenge of keeping these pits dry when steroids are flying through my system. I am like a one woman geyser for pete’s sake. Water isn’t just pouring into my body, it is flowing out as well. My skin feels like it is on fire as the sweat drips down my forehead. Ewww. Thanks a lot, prednisone.

Despite the many benefits, I can’t help but cringe when my doctor sends a script for prednisone my way. On one hand, I know that I will be on my way to feeling better. But on the other hand, I know what the cost will be. Each time I take it I can’t help but think, “My best friend, my worst enemy, we meet again.”

Whether or not to use systemic corticosteroids to treat a skin disease

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FRIDAY, Feb. 28, 2014 (HealthDay News) — Although corticosteroid pills are not recommended for the management of psoriasis, new research reveals these drugs are commonly prescribed by dermatologists treating this chronic skin condition.

Corticosteroids, including prednisone, dexamethasone and methylprednisolone, were the second most commonly prescribed systemic medications (not preparations applied to the skin) for psoriasis, according to a study from Wake Forest Baptist Medical Center.

“Expert guidelines discourage their use for psoriasis due to concerns about causing flares of generalized pustular psoriasis, but there are no randomized controlled trials of systemic corticosteroids in psoriasis to look at these issues,” study co-author Scott Davis, assistant director of the Center for Dermatology Research at Wake Forest Baptist Medical Center, said in a Wake Forest news release.

In conducting the study, recently published online in the Journal of Cutaneous Medicine and Surgery, the researchers examined survey data collected on systemic medications used to treat psoriasis from 1989 to 2010.

Out of 21 million office visits, corticosteroids were prescribed 650,000 times. The study’s authors noted the vast majority, or 93 percent, of these prescriptions were written by dermatologists.

“Psoriasis has an enormous impact on patients’ lives, and there have been major recent advances in treatment,” Davis noted. “While the new treatments are highly effective and appear very safe, they are costly; their effects are well studied. In contrast, while corticosteroids have been available for decades, their use in psoriasis has not been extensively studied.”

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