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• W4319160408 abstract "We applaud the publication by Kresch et al1Kresch M. Weingarten M. Guenin S. et al.Risk of rebound psoriasis flare from systemic corticosteroid use in patients with psoriasis: a retrospective cohort study. Preprint. Posted online December 17, 2022.J Am Acad Dermatol. 2022; https://doi.org/10.1016/j.jaad.2022.12.019Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar investigating the proportion of patients with psoriasis and rebound flares after systemic steroids. In this study, the authors found that 9 of 16 patients with psoriasis who were administered steroids had worsening skin disease compared with only 1 of 16 matched controls. The authors concluded that withdrawal of systemic steroids can cause psoriatic flares and should be avoided when possible. These conclusions, however, diverge from 2 recent systematic reviews,2Vincken N.L. Balak D.M. Knulst A.C. Welsing P.M. van Laar J.M. Systemic glucocorticoid use and the occurrence of flares in psoriatic arthritis and psoriasis: a systematic review.Rheumatology. 2022; 61: 4232-4244Crossref PubMed Scopus (5) Google Scholar,3Long V. Yew Y.W. Chandran N.S. Choi E.C. Psoriasis flares and rebound phenomenon following exposure and withdrawal of systemic steroids: a systematic review and meta-analysis.J Am Acad Dermatol. 2022; 87: 660-661Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar in which the authors separately found a low rate of psoriasis flares after systemic steroids and questioned the conventional belief of avoiding steroids in patients with psoriasis. We herein sought to investigate some reasons for this discrepancy. There is no accepted definition for a “flare.” Although Kresch et al1Kresch M. Weingarten M. Guenin S. et al.Risk of rebound psoriasis flare from systemic corticosteroid use in patients with psoriasis: a retrospective cohort study. Preprint. Posted online December 17, 2022.J Am Acad Dermatol. 2022; https://doi.org/10.1016/j.jaad.2022.12.019Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar defined it as a 10% increase in body surface area (BSA), studies in systematic reviews typically used a subjective patient or physician report of flare (which may be more stringent and may encompass a greater magnitude of worsening). This could explain why the proportion of skin flares (56%) in the study by Kresch et al1Kresch M. Weingarten M. Guenin S. et al.Risk of rebound psoriasis flare from systemic corticosteroid use in patients with psoriasis: a retrospective cohort study. Preprint. Posted online December 17, 2022.J Am Acad Dermatol. 2022; https://doi.org/10.1016/j.jaad.2022.12.019Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar was higher than those in the reviews (a range of 0%-1.42% reported by Vincken et al2Vincken N.L. Balak D.M. Knulst A.C. Welsing P.M. van Laar J.M. Systemic glucocorticoid use and the occurrence of flares in psoriatic arthritis and psoriasis: a systematic review.Rheumatology. 2022; 61: 4232-4244Crossref PubMed Scopus (5) Google Scholar and 0%-44%, with a pooled proportion of 15%, reported by Long et al3Long V. Yew Y.W. Chandran N.S. Choi E.C. Psoriasis flares and rebound phenomenon following exposure and withdrawal of systemic steroids: a systematic review and meta-analysis.J Am Acad Dermatol. 2022; 87: 660-661Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar). Although the clinical relevance of a 10% increase (eg, increase in BSA from 30% to 34%) is debatable, it can be argued that Kresch et al1Kresch M. Weingarten M. Guenin S. et al.Risk of rebound psoriasis flare from systemic corticosteroid use in patients with psoriasis: a retrospective cohort study. Preprint. Posted online December 17, 2022.J Am Acad Dermatol. 2022; https://doi.org/10.1016/j.jaad.2022.12.019Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar applied the same criteria to their control arm and still found a higher proportion of flares in the steroid arm. The validity of this finding, however, assumes baseline equivalence of the case and control groups. This assumption may not hold as patients in the steroid group may have had the following:•An active illness, necessitating oral steroids (whether unstable psoriasis or a separate condition), itself a strong risk factor for psoriatic flares;•Additional medications (nonsteroidal anti-inflammatory drugs, β-blockers) that can flare psoriasis;•Psoriasis medications (eg, biologics) withheld during their acute illness;•Closer follow-up and, thus, a higher likelihood of detection of increases in BSA. To further knowledge in this area, we propose a few directions. First, we believe that a composite definition of a flare (as has been previously used4Gregoire A.R. DeRuyter B.K. Stratman E.J. Psoriasis flares following systemic glucocorticoid exposure in patients with a history of psoriasis.JAMA Dermatol. 2021; 157: 198-201Crossref PubMed Scopus (17) Google Scholar,5Atalay S. van den Reek J.M. den Broeder A.A. et al.Comparison of tightly controlled dose reduction of biologics with usual care for patients with psoriasis: a randomized clinical trial.JAMA Dermatol. 2020; 156: 393-400Crossref PubMed Scopus (25) Google Scholar) may work better. This could comprise a percentage change or absolute increase in BSA, new-onset erythroderma or pustulation, or worsening of patient-reported outcomes. Second, one should separately analyze patients in whom steroids were prescribed for active psoriatic disease versus in whom they are prescribed for a separate medical issue. Additionally, researchers should match the control group for baseline disease activity and the medical issue to improve comparability between cases and controls. Studies can also compare the rate of psoriatic flares due to systemic steroids with alternative therapeutic options (eg, escalation of nonsteroidal anti-inflammatory drugs or nonsystemic modes of steroid delivery). We thank the authors for their work and emphasize that evidence in this area is still limited. Further, well-conducted studies with either randomization or careful selection of the control group is important to further shed light on this controversial topic. None disclosed." @default.
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• W4319160408 title "Comment on “Risk of rebound psoriasis flare from systemic corticosteroid use in patients with psoriasis: A retrospective cohort study”" @default.
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