2 responses to “Whether or not to use systemic corticosteroids to treat a skin disease”

  1. The information presented here is interesting, but anecdotal. If I am to weigh the risk and benefit of offering oral steroids to my patients I need to get a sense of how likely such adverse events are. I agree with Dr. Murray that it is important to know that this complication happens in the 50mg per day dosing range, and I thank her for her contribution – but a decision to abandon a traditional and highly effective treatment requires a better sense of absolute risk.

    The orthopaedic surgeon who put together the osteonecrosis case series discussed in this article sees a highly select population of those who suffer such complications. What was the denominator? I’ve been a family physician for 25 years now and, if you include respiratory indications for oral steroids, I probably write such a prescription every 4-6 weeks. Having written perhaps 250 prescriptions for oral steroids I have never seen this complication – although clearly that is too small a sample size to be meaningful.

    The next time your local Division of Family Practice gets together count heads, and years of practice, and ask how many cases of osteonecrosis secondary to oral steroids the group has seen. Barring an analysis of administrative data that tries to answer this question, the risk / benefit of common therapies is something only primary care clinicians (working together) can answer.

  2. I thank Dr. Scott Garrison for his thoughtful comments. Statistics are not my thing so am not able to provide a sense of absolute risk.
    I do think that the large cohort study by Dr. Feng-Chen Kao provides compelling evidence for the association of systemic corticosteroid use with both fracture-related arthroplasty and fracture-unrelated surgery. In a group of 21,995 users matched 1:1 with non-users followed over 12 years, the hazard ratio (HR) was double for steroid users over non-users.
    The HR increased with increased steroid dosage, particularly in those with fracture-unrelated arthropathy. The adjusted HR increased from 3.30 (95% CI, 2.44–4.46) in the low-dose subgroup, 4.54 (95% CI, 3.05–6.77) in intermediate-dose users, to 6.54 (95% CI, 4.74–9.02) in the high-dose counterpart (Ptrend<0.0001).
    I think the most important point is that systemic corticosteroids are not a substitute for topical corticosteroids. They are a potent, broad-spectrum immunosuppressive agent and need to be prescribed with the same cautions you would use with any other immunosuppressive agent.
    Topical corticosteroids are potent immunosuppressants but with normal use, rarely cause systemic symptoms. Our skin is an excellent barrier.
    I remember seeing a sixteen-year-old girl who had been prescribed clobetasol cream to treat her atopic dermatitis. It cleared her disease. However, she continued to apply it to her skin every morning after her shower to prevent the eczema from coming back.
    She continued the daily treatment for a year. By that time, she had developed severe striae over her arms and legs. She was assessed by an endocrinologist and had no evidence of adrenal suppression.

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