Psoriasis

Psoriasis Flare Rates Low in Patients Receiving Systemic Corticosteroids

Colby Stong
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Pustular psoriasis of pregnancy (PPP) is a rare, life-threatening disease.8 It is sometimes referred to as impetigo herpetiformis, but many dermatologists consider this a misnomer because PPP is not associated with the herpes virus or bacterial infection.8 Although it is unclear whether PPP is specific to pregnancy, it typically arises early in the third trimester in affected women.3,8 Sterile erythematous plaques studded by painful pustules originate in skin folds on the trunk and back before coalescing into large dry desquamating plaques that spread to the extremities.2,8 Symptoms include fever, nausea, and diarrhea. Patients may also have neutrophilia, electrolyte abnormalities, and elevated inflammatory markers.2,8 Aggressive treatment is required and usually consists of systemic corticosteroids.8 Untreated PPP can lead to placental insufficiency, intrauterine growth restriction, and even miscarriage or stillbirth.8 Pregnant women with PPP and their fetuses should be closely monitored.2,8

Pustular psoriasis of pregnancy (PPP) is a rare, life-threatening disease.8 It is sometimes referred to as impetigo herpetiformis, but many dermatologists consider this a misnomer because PPP is not associated with the herpes virus or bacterial infection.8 Although it is unclear whether PPP is specific to pregnancy, it typically arises early in the third trimester in affected women.3,8 Sterile erythematous plaques studded by painful pustules originate in skin folds on the trunk and back before coalescing into large dry desquamating plaques that spread to the extremities.2,8 Symptoms include fever, nausea, and diarrhea. Patients may also have neutrophilia, electrolyte abnormalities, and elevated inflammatory markers.2,8

Aggressive treatment is required and usually consists of systemic corticosteroids.8 Untreated PPP can lead to placental insufficiency, intrauterine growth restriction, and even miscarriage or stillbirth.8 Pregnant women with PPP and their fetuses should be closely monitored.2,8

Do steroids induce severe psoriasis flares at significant rates in a general psoriasis population?

The rate of psoriasis flares in patients during or in the months immediately following administration of systemic corticosteroids is very low, and the rate of severe psoriasis flares is extremely low, researchers reported in a study published in JAMA Dermatology.

In this retrospective cohort study, the investigators assessed adult patients (18 years or older at the time of psoriasis diagnosis) who had been exposed to at least 1 systemic corticosteroid from October 31, 2012, to July 1, 2018. The primary outcome was rate of psoriasis flares during or within 3 months of discontinuing the first course of systemic corticosteroids. Secondary outcome measures included the rates of specific types of psoriasis flares, such as pustular, erythrodermic, and worsening plaque stage psoriasis.

A total of 1970 patients with established psoriasis received systemic corticosteroids; 516 patients were manually validated (288 [55.8%] women, mean [standard deviation, SD] age at first psoriasis diagnosis 49.6 [17.0] years).

From the 516 manually abstracted patient medical records, 16 psoriasis flares were identified. Among the 243 patients with psoriasis encounters during the corticosteroid period, 14 (5.8%) had psoriasis flares. In addition, 2 of 442 patients without psoriasis encounters had psoriasis flares, and 15 patients with flaring (93.8%) had worsening plaque psoriasis. Also, researchers identified 1 erythrodermic psoriasis flare and no pustular psoriasis flares.

The calculated overall 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%).

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“Our results suggest that systemic steroids may be much less likely to trigger severe flares in patients with psoriasis than what is traditionally taught in dermatology,” stated the researchers.

Among several study limitations, the investigators noted that their study was retrospectively performed at 1 large Midwest healthcare system and they do not know the severity of the patients’ psoriasis when corticosteroid therapy commenced. Also, they could not determine patient adherence, and there was no control population of patients with psoriasis not receiving systemic corticosteroids to compare flare rates.

“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,” the study authors commented. “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.”

Reference

Gregoire ARF, DeRuyter BK, Stratman EJ. Psoriasis flares following systemic glucocorticoid exposure in patients with a history of psoriasis. Published online November 18, 2020. JAMA Dermatol. doi:10.1001/jamadermatol.2020.4219

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