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Psoriasis Flares Following Systemic Glucocorticoid Exposure in Patients With a History of Psoriasis

Education Objective
To determine the rates of types of psoriasis flares during or immediately after systemic corticosteroid administration in patients with known history of psoriasis.
1 Credit CME
Key Points

Question  What is the rate of any type of psoriasis flare during or within 3 months of concluding systemic corticosteroid administration for any reason in patients with a known history of psoriasis?

Findings  In this cohort study of 1970 patients, the rate of psoriasis flare during or in the months immediately following the administration of systemic corticosteroids was very low, and the rates of severe psoriasis flares, including erythrodermic and pustular psoriasis, were extremely low. When flares occurred, patient history indicated an unlikely association with systemic corticosteroids.

Meaning  Dermatologists are taught to avoid systemic steroids in psoriasis patients because of disease flare risk, but although flares can occur, the rates and severity of flaring are very low.

Abstract

Importance  To our knowledge, this study is the first to assess the rate of any type of psoriasis flare during or immediately following the administration of systemic corticosteroids in patients with a known history of psoriasis.

Objective  To determine 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.

Design, Setting, and Participants  This retrospective cohort study assessed adult patients (≥18 years at the time of psoriasis diagnosis) evaluated in the Marshfield Clinic Health System (Marshfield, Wisconsin) with an established diagnosis of psoriasis and exposure to at least 1 systemic corticosteroid from October 31, 2012, to July 1, 2018. Exclusion criteria were patients younger than 18 years, patients with a diagnosis of psoriatic arthritis, and patients receiving only topical, intraarticular, or intrabursal corticosteroids.

Main Outcomes and Measures  The primary outcome was rate of psoriasis flares during or within 3 months of discontinuation of the patient’s first course of systemic corticosteroids. Secondary measures included rates of specific types of psoriasis flares, including pustular, erythrodermic, and worsening plaque stage psoriasis.

Results  Of 516 cohort patients, 288 (55.8%) were women, and the mean (SD) age at first psoriasis diagnosis was 49.6 (17.0) years. Among 1970 patients with a diagnosis of psoriasis before receiving systemic corticosteroids, a 1.42% (95% CI, 0.72%-2.44%) psoriasis flare rate of any type was identified when prescribed their first course of systemic corticosteroids. Further stratification identified only 1 severe flare (erythroderma) among all flares reported, with no pustular psoriasis flares identified (0.07%; 95% CI, 0.00%-0.26%).

Conclusions and Relevance  In this study, the rates of psoriasis flares were low, especially for severe psoriasis flares. 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.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: September 4, 2020.

Published Online: November 18, 2020. doi:10.1001/jamadermatol.2020.4219

Corresponding Author: Erik J. Stratman, MD, Department of Dermatology, Marshfield Clinic, 3P2, 1000 N Oak Ave, Marshfield, WI 54449 (stratman.erik@marshfieldclinic.org).

Author Contributions: Dr Stratman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Gregoire, Stratman.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Gregoire, Stratman.

Obtained funding: Gregoire.

Administrative, technical, or material support: DeRuyter.

Conflict of Interest Disclosures: None reported.

Funding: This study was funded by a Marshfield Clinic Health System Residency Research grant.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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