Systemic glucocorticoid use and the occurrence of flares in psoriatic arthritis and psoriasis: a systematic review

Objectives The use of systemic glucocorticoids (SGC) is traditionally discouraged in the treatment of psoriatic arthritis (PsA) and psoriasis due to risk of psoriatic flares. However, despite this recommendation, SGC are frequently prescribed for these patients. In this study we reappraise the old paradigm that SGC are contra-indicated in the treatment of PsA and psoriasis. Methods A systematic search of MEDLINE, EMBASE and the Cochrane Library databases was performed in November 2019 to identify articles on any SGC use compared with no use in the PsA and psoriasis population. Topical glucocorticoid treatment was excluded. Our two primary outcomes focused on prescribing characteristics and occurrence of any type of flare. Results Our search yielded 4,922 articles of which 21 full-text were eligible for inclusion. There were eleven retro- and prospective cohorts involving a total of 4,170 820 patients of which 6,727 (37,82%) PsA and 1,460 793 (35,17%) psoriasis patients were treated with any type of SGC. Ten observational/interventional studies did not report an increased risk or occurrence of psoriatic flares related to SGC use. Conclusion Our results indicate that SGC are frequently prescribed for PsA and psoriasis patients. The occurrence of psoriatic flares appears to be low upon SGC exposure. In patients with a clear indication for SGC, e.g. in need of rapid anti-inflammatory therapy or bridging of therapies, the use of SGC should be considered in view of a low risk of skin flaring. It remains of importance to weigh risks for short- and long-term SGC-related side effects in clinical decision making.