Psoriasis Flare Rates Low Among Systemic Corticosteroid Users

Anna Gregoire, MD

Recent study findings indicate flares during or immediately following the administration of systemic corticosteroids are low in patients with a known history of psoriasis.

The findings suggested systemic steroids may be much less likely to trigger severe flares than what was traditionally taught in dermatology.

Anna Gregoire, MD, and a team of investigators determined the rates and types of psoriasis flares during or within 3 months after concluding systemic corticosteroid administration in adult patients with a known history of psoriasis. The team assessed patients at least 18 years old with an established diagnosis of psoriasis and exposure to at least 1 systemic corticosteroid. Patients were excluded if they were younger than 18 years old, had a diagnosis of psoriatic arthritis, and if they received only topical, intraarticular, or intrabursal corticosteroids.

The electronic health record was used to identify systemic corticosteroid prescriptions. Gregoire and the team collected dose and tapering strategies.

Investigators defined flaring as the presence of at least 1 of the following: documented increases of body surface area involvement, higher psoriasis area and severity index score, presence of pustular or erythrodermic skin, patient subjective report of worsening, physical examination results showing worsening psoriasis compared to previous examination, and clinician assessment or plan with mention of flare, rebound, or worsening psoriasis. Severe flare was considered pustular psoriasis or generalized erythroderma.

Overall, 516 patients with established psoriasis who received systemic corticosteroids were manually validated. The mean age at the initial psoriasis diagnosis was 49.6 years old. A majority of the patients (55.8%) were women. The mean age at first prescription was 61.3 years old and the median corticosteroid dose in those with and without psoriasis flares was 40 mg.

Of the 516 patients included, 16 psoriasis flares were identified. Among 243 patients with psoriasis encounters during the corticosteroid period, 14 experienced flares. There were 2 patients out of 442 without psoriasis encounters who experienced flares.

A majority of patients (93.8%) with flaring experienced worsening plaque psoriasis. The overall flare rate was 1.42% (95% CI; .72-2.44). The calculated severe flare rate was .07% (95% CI, 0-.26).

There were 3 patients with flaring who had guttate psoriasis flares with objective evidence of current or recent Streptococcal infection. Nearly 40% of patients indicated their flares began before receiving systemic corticosteroid prescriptions.

Despite some patients experiencing psoriasis flares, the rates overall were low among patients receiving systemic corticosteroids for any reason. Overall, less than 1.5% of patients developed psoriasis flares and a majority of flares involved worsening plaque psoriasis.

Investigators noted the results did not support that patients with psoriasis who received or tapered off systemic corticosteroids had significant rates of severe psoriasis flares. In fact, the study added to evidence that the frequency of any type of psoriasis flare was very low in patients with psoriasis receiving such prescriptions.

The team suggested strict avoidance of such prescriptions among patients with psoriasis may be unnecessary.

The study, “Psoriasis Flares Following Systemic Glucocorticoid Exposure in Patients With a History of Psoriasis,” was published online in JAMA Dermatology.