Pustular and Erythrodermic Psoriasis in Patients Treated With Oral Glucocorticoids: A Survey of United States Dermatologists
April 2022 | Volume 21 | Issue 4 | Features | 427 | Copyright © April 2022
Published online March 25, 2022
Katherine C. Awh BA,a Christian A. Albornoz MD,a Kumar S. Nadhan MD,b Meghan Buckley MS,c Steven R. Feldman MD,d M. Anthony Albornoz MDe
aThomas Jefferson University, Philadelphia, PA
bCook County Health, Chicago, IL
cLankenau Institute for Medical Research, Wynnewood, PA
dWake Forest School of Medicine, Winston-Salem, NC
eRiddle Memorial Hospital, Media, PA
Abstract
Dermatology dogma has cautioned against the use of orally administered glucocorticoids (OAG) in the treatment of psoriasis, largely due to concerns of life-threatening generalized pustular psoriasis (GPP) and erythrodermic psoriasis (EP). However, studies show that OAG are frequently used for psoriasis, often by dermatologists. Given the widespread use of OAG, we see an urgency in examining the relationship between OAG usage and the development of GPP and EP. This anonymous electronic survey of 50 US dermatologists examines OAG use in the management of psoriasis and the frequency at which dermatologists report seeing associated adverse outcomes of GPP and EP. Overall, 9 out of 50 (18%) respondents occasionally prescribe OAG to patients with psoriasis. Dermatologists who prescribe OAG tended to be younger than those who did not, with two-thirds in clinical practice for 0-10 years. Among all respondents, 16% (8/50) had experienced one or more patients developing GPP/EP in the context of OAG treatment for psoriasis. Our study suggests that OAG for the management of psoriasis is not uncommon among U.S. dermatologists, despite nearly universal awareness of its risks. Our observed low prevalence of GPP and EP emphasizes the need for prospective studies to better characterize OAG’s risk/benefit profile in psoriasis.
J Drugs Dermatol. 2022;21(4):427-429. doi:10.36849/JDD.6242
INTRODUCTION
Dermatology dogma has cautioned against the use of orally administered glucocorticoids (OAG) in the treatment of psoriasis. This is due largely to concerns of generalized pustular psoriasis (GPP) and erythrodermic psoriasis (EP), as well as long-term glucocorticoid side effects.1,2 However, OAG are frequently used for psoriasis, often by dermatologists.3,4 Treatment outcomes data are sparse, but rates of severe psoriasis flares may be low in psoriasis patients who receive systemic corticosteroids.5,6 Given the widespread use of OAG, we see an urgency in examining the relationship between OAG usage and the development of GPP and EP. This survey of US dermatologists examines OAG use in the management of psoriasis and the frequency at which dermatologists report seeing associated GPP and EP.
MATERIALS AND METHODS
Fifty U.S. community and university-based dermatologists completed an online survey consisting of 14 questions. This study was approved by the Main Line Health Institutional Review Board. Investigators were blinded to the respondent's identifying information. Respondents provided informed consent without financial compensation. Dermatologists selected responses based on their OAG prescribing habits in the management of psoriasis and their contextual experience with GPP and EP. Information on parenterally administered glucocorticoid (PAG) use, management objectives, duration of treatment, and disease outcomes were also collected.
RESULTS
Most of the dermatologists surveyed have been in clinical practice for greater than 10 years and see between 6-10 patients with psoriasis per week (Figure 1-A). Overall, 9 out of 50 (18%) respondents reported occasionally prescribing OAG to patients with psoriasis, typically 1-5% of the time (Figure 1-B). Dermatologists who prescribe OAG tended to be younger than those who did not, with two-thirds in clinical practice for
