Systemic corticosteroids, in conjunction with methotrexate, may be beneficial for controlling the acute phase of psoriatic erythroderma and preventing erythroderma rebound after tapering off in a patient with unstable psoriasis and multiple comorbidities, according to finding from a case report published in Dermatologic Therapy.

This case study included a 37-year-old man with unstable psoriasis with a duration of approximately 20 years. The patient presented with a new episode of erythroderma after a recent upper respiratory tract infection. A 10-day course of cefoperazone/ sulbactam and 7-day course of clindamycin was administered for infection.

Comorbidities in this patient included psoriatic arthritis, IgA nephropathy, chronic heart failure, non-alcoholic steatohepatits, history of infection with hepatitis B virus (negative AgHbs, positive anti-HBs and anti-Hbc antibodies), and obesity.

Approximately 1 month before this episode, he had ceased treatment of 15 mg/week methotrexate. Treatment with infliximab and adalimumab was unsuccessful due to the development of antibodies against each drug. The Psoriasis Area and Severity Index score at time of admittance to the clinic was 70.8, which was suggestive of “maximal” disease.


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Systemic therapy, including intravenous hydrocortisone hemmisuccinate (HHC) at 6 mg/kg (600 mg/day) and 10 mg/week methotrexate, was initiated in combination with classic topical therapy and supportive care. Intravenous HHC was tapered slowly during a 2-week period, whereas methotrexate increased to 15 mg/week.

Treatment response was good, aside from transient hyperglycemia. The disease did not rebound after discontinuation of HHC, nor did any other complications occur during this time. The PASI was 47.2 after 14 days, representing a 33% decrease. At discharge, the patient was indicated to continue methotrexate.

The patient had stable disease over a 1-year postdischarge follow-up period. During a 2-year period after the 1-year follow up, the patient received 80 mg ixekizumab every 4 weeks and switched to 300 mg secukinumab every 4 weeks. This treatment produced modest results and wasn not sufficient to control disease.

A potential limitation of this case report was the reliance on outcomes data from a single patient.

The case study authors wrote that “systemic corticosteroids are considered controversial in psoriatic erythroderma; therefore, they may be used with caution in exceptional cases.”

Reference

Cretu S, Salavastru CM, Tiplica GS. Treatment of psoriatic erythroderma using systemic corticosteroids: a timeless option? Published online August 21, 2020. Dermatol Ther. doi:10.1111/dth.14222