Dr. Eileen Murray MD FRCPC (biography and disclosures) Disclosures: Served as a consultant for the pharmaceutical industry and participated in clinical research evaluating new therapies for psoriasis and atopic dermatitis. Mitigating potential bias: Treatments or recommendations are unrelated to products/services/treatments involved in disclosure statements.
What I did before
When I started out in dermatology, corticosteroids were the only systemic drug available to treat patients with severe allergic contact dermatitis (ACD), atopic dermatitis (AD), drug reactions and those with bullous diseases.
Corticosteroids are potent and excellent immunosuppressive agents. The main problem with systemic use is the high risk of drug interactions, as well as multiple serious acute and long-term side effects.
It was the belief at the time that patients treated oral corticosteroids for short periods, two weeks or less for instance were not adversely affected by treatment.
Severe ACD caused by poison ivy was the disease I treated most frequently with systemic corticosteroids. Patients were given a two-week course of oral Prednisone, 50mg daily for seven days and 25mg daily for another seven (total dose of 525mg). Two weeks of treatment was necessary to prevent recrudescence and completely clear the eruption.
What changed my practice
The following article made me change the way I treated ACD and stimulated me to try to avoid using systemic corticosteroids when at all possible. McKee et al (1) reported a group of male patients who had developed osteonecrosis six to thirty-three months after a single short-course of oral corticosteroids within three years of presentation. The mean steroid dose in equivalent milligrams of prednisone was 850 (range 290–3300) mg. The mean duration of drug therapy was 20.5 (range 7–39) days.
Osteonecrosis is a known complication of systemic corticosteroid use and was initially believed to occur only in patients who received high doses (equivalent to more than 4000 mg of prednisone) for extended periods (3 months or longer).
I was that impressed that three of the fifteen of McKee’s patients had been treated for poison ivy.
What I do now
1. Allergic contact dermatitis:
Each patient with ACD is instructed to apply a wet dressing (3,4) (see Patient handout) three times daily for 15 to 20minutes followed by the application of clobetasol propionate cream – the most potent topical corticosteroid. The patient continues the wet dressings daily until they are no longer itchy. Soon after changing my practice, I had a series of patients with severe, generalized ACD appearing two days post surgery. Systemic treatment would have interfered with post operative healing. All of them were treated with the topical regime and had quick relief of itching. Their ACD cleared just as quickly as those patients I had previously treated with systemic corticosteroids.
2. Psoriasis and chronic urticaria: do not treat either of these diseases with systemic corticosteroids!
- Oral corticosteroids will clear psoriasis. However, when the drug is discontinued the disease recurs, is much worse and much more resistant to other treatments.
- Chronic urticaria (defined as daily or almost daily hives for longer than six weeks), is one of the most difficult diseases to manage. In most cases it is impossible to determine the cause. Therefore, it is important to treat with drugs that are safe to use long-term.
3. Do not treat undiagnosed skin disease or itching with systemic corticosteroids:
Case 1
A young man in the middle of the night presented to the emergency with a generalized rash and severe itching; so severe he was begging for relief. Three weeks previously he had been seen in a walk-in clinic and prescribed a one-week course of oral prednisone. A week later, no better, he saw his family physician and was given an antifungal cream. Within the week, he was seen at another walk-in clinic and given a topical corticosteroid. The rash continued to get worse culminating in his visit to emergency where he was being treated with IV Solu-Medrol and antihistamines.
He had the most severe case of pityriasis rosea (PR) I have ever seen. I discontinued his corticosteroids, prescribed a 10-day course of erythromycin and a compounded cooling lotion containing 0.25% menthol and asked him to come to my office the next morning. By then his itch had subsided. His rash cleared within five days. In this case, the initial treatment with oral corticosteroids had increased the severity of the disease so much that none of the physicians he saw subsequently were able to make a clinical diagnosis.
The etiology of PR is still not known. It may be a reaction to unknown triggers. Most cases are mild and resolve spontaneously without treatment. Recent studies have suggested an infectious etiology might be responsible. Both oral erythromycin and acyclovir have been reported to clear patients with severe disease (5).
Case 2
An older male patient, within hours of inadvertently ingesting one cloxacillin capsule, presented with fever, facial swelling, diffuse erythema and numerous pin-sized non-follicular pustules. He was otherwise well. I suggested that he be admitted and observed overnight. That evening, I found an article describing a series of patients with the same presentation – an unusual and rare drug reaction designated as acute generalized exanthematous pustulosis. (AGEP). The good news, it resolves spontaneously within a few days. I stopped at the hospital early the next morning. I was too late; his physician had treated him with overnight with IV solu-medrol.
4. Treating with topical corticosteroid is sometimes as effective for skin disease as the systemic drug:
There is evidence to show that treating severe bullous diseases with potent topical corticosteroids can be as effective as treating with systemic. Topical treatment is very much safer as very little of the drug is absorbed even with open lesions. Also, as the skin heals even less corticosteroid is absorbed.
5. Bullous pemphigoid (most common in elderly patients) is now often treated with topical corticosteroids alone or in combination with high doses of tetracycline and niacinamide (6,7).
6. If you feel that you might need to treat with systemic corticosteroids:
- Have an unequivocal diagnosis. (Biopsy a lesion if you are not sure)
- If possible, eliminate the cause (drug or herb, allergen)
- Treat with a super potent topical corticosteroid before considering systemic treatment.
- Rule out chronic infectious disease
- Treat confounding factors (dry skin).
- Consider other options, including the topical immunosuppressive drug – tacrolimus.
- Consider other immunosuppressive agents – oral retinoids, methotrexate or biologics.
- Have a detailed treatment plan.
- Treat for the shortest possible time.
- Institute osteoporosis prevention for longer treatment courses.
Patients who may require systemic corticosteroids include patients with severe or unresponsive disease or those intolerant to other treatment. Diseases most frequently treated include drug reactions, AD, nummular dermatitis, ACD, bullous pemphigoid and lichen planus.
Patient Handout:
Open Wet Dressings
- Prepare one of the solutions as recommended by your doctor. The solution should be cool, tepid or warm but not hot or cold.
- Dissolve 1 packet of dermboro™ powder (makes an aluminum acetate solution) in 2 cups of water. OR
- Dissolve 1 tsp of salt in 2 cups of water. OR
- Mix equal parts milk and water (infrequently used and most often for facial rashes).
- Wet a soft cotton cloth with the solution (an old sheet or diaper or cotton t-shirt cut to fit the affected area) and wring out the cloth so that it is wet but not dripping.
- Apply one or two layers of the wet cloth to the skin and leave on for ___ minutes. Repeat ___ a day.
- Keep the cloth wet for the entire application time by taking it off and rewetting it or by pouring some of the solution directly onto it.
- Remove the wet cloth and apply the medication prescribed to the damp skin.
From: Murray Eileen, Diagnosing Skin Diseases: A diagnostic tool and educational resource for pediatricians and primary care givers.
Note: Wet dressings are cool and soothing, antipruritic, and antiseptic. They also enhance absorption of topical medications. They are the epitome of a treatment that always helps and never harms. For skin diseases with weeping or crusting a wet dressing open to the air dries the lesions. If the skin is dry an occluded wet dressing increases moisture retention. Physicians began using wet dressings several hundred years ago. Solutions were compounded by surgeons treating wounded soldiers. Many lives were saved because the wet dressings greatly reduced the risk of infection. The most common solution available now, is an advanced version, (dermburo™) of the solution invented by Dr. Karl August Burow, (1809-1874) -a German surgeon, an inventor of both plastic surgery and wound healing techniques.
References and/or Additional reading:
- McKee M, Waddell J, Kudo P, Schemitsch E, Richards R. Osteonecrosis of the femoral head in men following short-course corticosteroid therapy: a report of 15 cases. Can. Med. Assoc. J. 2001;164:205-206. (View)
- Kao F, Hsu Y, Lin C, Lo Y, Tu Y. Corticosteroid Is associated with both hip fracture and fracture-unrelated arthropathy. PLoS ONE. 2017;12:e0169468. (View)
- Hurwitz S. Clinical Pediatric Dermatology. 2nd ed. Philadelphia: WB Saunders Company;1993:56.
- Bernhard Jeffery D. Editor. Itch: Mechanisms and Management of Pruritus. Litt, JZ, Topical treatment of itching without corticosteroids. McGraw-Hill,Inc;1994:285-386
- Amatya A, Rajouria EA, Karn DK. Comparative study of effectiveness of oral acyclovir with oral erythromycin in the treatment of Pityriasis rosea. Kathmandu. Univ. Med. J. (KUMJ). 2012;10:57. (Request with CPSBC or view UBC)
- Fivenson DP, Breneman DL, Rosen GB, Hersh CS, Cardone S, Mutasim D. Nicotinamide and tetracycline therapy of bullous pemphigoid. Arch. Dermatol. 1994;130:753-758. (Request with CPSBC or view UBC) DOI:10.1001/archderm.1994.01690060083010
- Joly P, Roujeau J, Benichou J, et al. A Comparison of Oral and Topical Corticosteroids in Patients with Bullous Pemphigoid. N. Engl. J. Med. 2002;346:321-327 (Request with CPSBC or view UBC) DOI:10.1056/NEJMoa011592
- Kasperkiewicz M, Zillikens D, Schmidt E. Pemphigoid diseases: Pathogenesis, diagnosis, and treatment. Autoimmunity. 2012;45:55-70. (Request with CPSBC or view UBC) DOI:10.3109/08916934.2011.606447
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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.
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.
The proof is in Case 1 & 2. I’m thankful for this information.
I found this very insightful. I personally do not like using steroids, and feel many guidelines that recommend it (apparently the new ones for severe pneumonia in the hospital) are saying it prevents death, and that is definitely possible (because those patients are on the verge of death). Community hospitals use steroids for pneumonia (out of the ICU) much more commonly than academic centers. It is easy to see why-it makes people feel better faster. But what are the longer-term consequences? I don’t think we know.
The study you brought up points out that there are long term consequences that the immediate practitioner almost never sees, and there is always that bias (because usually a serious complication is fixed by another specialty).
I personally feel our medical field (likely cause society has changed) has moved away from thinking about longer-term issues and just focusing on making people feel better right away. Today I started a patient on a steroid taper, though I know most others would have increased the steroid to treat the allergic dermatitis that bothered her so much. But I do wonder about the futility, cause she can just as easily go see someone else …