Long-term use of systemic corticosteroids in a patient with psoriasis vulgaris - clinical case report

Abstract

Corticosteroids (CS) are drugs widely used in medicine [1]. Due to its anti-inflammatory and immunosuppressive effects, they are administered in the treatment of many steroid-responsive dermatoses, including psoriasis. Topical CS are one of the most common topical treatments for psoriasis [2]. At the same time, the use of systemic CS in the treatment of psoriasis is not recommended by dermatological manuals and guidelines because of the risk of worsening the disease after reducing or withdrawing the dose [3]. However, despite this recommendation, CS are frequently prescribed to these patients [4]. Objective of the study Reevaluation of the paradigm according to which systemic CS are contraindicated in the treatment of psoriasis, based on one clinical case. Clinical case The case of a male patient 56 year-old, with widespread skin lesions on the face, trunk and limbs, joint pain in the elbows, hands, hips and knees. He is considered sick with psoriasis vulgaris, the nummular form, for 18 years. Initially, the process had a mild evolution, where the area of skin damage did not exceed 3%. Under the action of weekly treatment with sol.Flosteron 7mg/1ml i/m, applied independently over 15 years, the patient noticed the gradual decrease of the therapeutic effect with the progressive worsening of psoriasis. Dermatological status: At the level of the trunk, upper and lower limbs, there are multiple well-defined nummular and lenticular papules, red in color, covered by pearly-white scales, which detach easily. Positive psoriatic triad. Onychodystrophy is manifested by the yellowish coloring of the nail plate, pitting and longitudinal striations. On the face, chest and limbs, signs of post-medicated Cushing’s syndrome characterized by: full moon face, buffalo hump, stretch marks, skin atrophy, upper type obesity, in some places hematomas caused by vessel fragility, telangiectasias. The established diagnosis was Psoriasis vulgaris, the nummular form, with severe evolution, with the area of skin damage greater than 10%. Paraclinical investigations: Cortisol level- 0.95 (norm 5.1- 17 ug/dL). X-ray of the hip: Bilateral coxarthrosis, on the right gr.I, on the left gr. II, osteoporosis. Treatment with topical CS, phototherapy and systemic cytostatics (sol. Methotrexate 15 mg/week) was indicated, but without significant improvement. Discussions Uncontrolled long-term use of CS leads to multiple adverse effects, both cutaneous and systemic. Systemic CS are contraindicated in patients with psoriasis vulgaris, because they can worsen the evolution of the skin process, with the transformation of mild forms of psoriasis into severe forms, such as pustular psoriasis and erythroderma. At the same time, there is a delay in the expected effect from standard psoriasis treatment methods. Conclusions In this study we agree with the old paradigm that systemic CS are contraindicated in the treatment of psoriasis vulgaris.