Topical steroids in psoriasis

Some points concerning the use of corticosteroids in psoriasis:

• they can be used topically or systemically
• the response relates directly to dose: 1% hydrocortisone has very little effect whereas the most potent preparations, such as clobetasol propionate, work rapidly
• with repeated use, tolerance will develop - repeated application inevitably results in some skin atrophy
• action appears to be suppressive - improvement only occurs while they are being applied
• often reserved for 'crisis' intervention - to give rapid improvement when this is necessary for social reasons, and for difficult areas such as the flexures and face, on which only moderately potent preparations should be used
• in general, given for short periods of time and alternated with other forms of treatment
• in comparison to vitamin D analogues
  • a systematic review found that in head-to-head comparisons of vitamin D against potent or very potent corticosteroids there were no significant differences in efficacy. However, combined treatment with vitamin D /corticosteroid performed significantly better than either vitamin D alone or corticosteroid alone. Potent corticosteroids were less likely than vitamin D to cause local adverse events.(1)

A suggested protocol for use of topical preparations with respect to NICE guidance (2) is linked.

How to use corticosteroids safely

• be aware that continuous use of potent or very potent corticosteroids may cause:
  • irreversible skin atrophy and striae
  • psoriasis to become unstable
  • systemic side effects when applied continuously to extensive psoriasis (for example more than 10% of body surface area affected)
• explain the risks of these side effects to people undergoing treatment (and their families or carers where appropriate) and discuss how to avoid them
• Aim for a break of 4 weeks between courses of treatment with potent or very potent corticosteroids
  • consider topical treatments that are not steroid-based (such as vitamin D or vitamin D analogues or coal tar) as needed to maintain psoriasis disease control during this period
• When offering a corticosteroid for topical treatment select the potency and formulation based on the person's need
  • do not use very potent corticosteroids continuously at any site for longer than 4 weeks
  • do not use potent corticosteroids continuously at any site for longer than 8 weeks
  • do not use very potent corticosteroids in children and young people
• Medication review if on topical steroid treatment for psoriasis
  • offer a review at least annually to adults with psoriasis who are using intermittent or short-term courses of a potent or very potent corticosteroid (either as monotherapy or in combined preparations) to assess for the presence of steroid atrophy and other adverse effects
  • offer a review at least annually to children and young people with psoriasis who are using corticosteroids of any potency (either as monotherapy or in combined preparations) to assess for the presence of steroid atrophy and other adverse effects

Reference:

1. Mason AR, Mason J, Cork M, Dooley G, Edwards G. Topical treatments for chronic plaque psoriasis.Cochrane Database Syst Rev. 2009 Apr 15;(2):CD005028.
2. NICE (October 2012). Psoriasis - the assessment and management of psoriasis