Corticosteroids , In the Treatment of Skin Disorders

8/9/2019 Corticosteroids , In the Treatment of Skin Disorders

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Whos Afraid of

Cortisone?

Corticosteroids

in the Treatment of Skin Disorders


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Foreword

Corticosteroids play an important role in

the treatment of many skin disorders and have

been used very successfullysometimes in

combination with other medicinesto treatboth the acute stages of a disease as well as

chronic illnesses.

Despite corticosteroids high success rate, the

very word cortisone often evokes fear and

mistrust in patients. There are a number of

reasons for this fear that include: concernabout corticosteroids side-effects, doubt that

such a strong medicine is really necessary,

and anxiety about all the misinformation

currently associated with corticosteroids.


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The informed patient wants clear, comprehensive

information about all aspects of

corticosteroids, which is exactly what this

patient advisory brochure is offering. It

explains the differences between the

external and the internal use of corticosteroids,

the varying potencies available,

what kind of symptoms require which

specific treatment, and last but not least,

how serious side-effects can be avoided.

The better informed a patient is, the less he

or she will suffer from confusion and fear.

This brochure significantly contributes

towards a better understanding and wider

acceptance of the treatment of skin disorders

with corticosteroids, by clarifying

their effects and demonstrating the importanceof this kind of medication.

Foreword

Prof. Dr. med.

Roland Niedner

Director, Skin ClinicPotsdam


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Contents

I.The Basics of

Corticosteroids

1. Whos Afraid of

Cortisone?

2. A Look at the History

of Corticosteroids3. How Do Corticosteroids

Work?

II. Corticosteroid

Therapy

1. When Are Corticosteroids

Used?

2. Why Are Corticosteroids

Used?

3. Treatment from the

Outside

4. Cream or Ointment

the Role of Galenics

III. When Doctors Prescribe

Corticosteroids

1. The Doctors Diagnosis andRecommended Treatment

2. The Patients Co-operation

3. An Overview:

the Most Common Uses

of Corticosteroids

IV. MisunderstandingsAbout Cortisone

1. The Ten Most Common Error

2. The Package Insert


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The Basics of

Corticosteroids

1. Whos Afraid of Cortisone?

2. A Look at the History ofCorticosteroids

3. How Do Corticosteroids Work?


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1. Whos Afraid of Cortisone?

First of all, cortisone as such is not amedication, it is a natural hormone that is

produced in the adrenal gland. To be more

precise this hormone is called hydrocortisone

or cortisol. In terms of medication, the

active ingredients are called corticosteroids

and are a subcategory of steroids, along with

all artificial hormones of a specific molecular

structure. Therefore, in the following text, we

will be speaking of cortisone as the naturalhormone and a corticosteroid as its artificial

twin.

The adrenocortical hormone cortisone performs

vital functions for the human body, without

which life would not be possible. During times

of stress, the body increases production of the

natural cortisone which helps it to cope in

situations like car accidents, or excessive

mental strain, or even inflammation or fever.At the same time, it regulates the metabolic

processes and protects against allergies.

Produced by artificial cloning,this

Multitalented medication has been around for

Decades as a drug. Corticosteroids are used to

treat rheumatism; asthma; skin and kidney

disease;arterial, blood, intestinal, and liver

disorders;nervous disorders and shock; and

Organ transplant patients. Why, then, doso many people mistrust this drug?

Cortisone for my child? Never!" Even today,doctors still hear this kind of reaction when

they recommend treatment withCorticosteroids for atopic eczema

(neurodermatitis),

for example, or other eczema. Many people

refuse to be treated with corticosteroids, and

even when they accept it, they have strong

reservations.

On the one hand, many have had good

Experiences with corticosteroids, while on

the other, misunderstanding and prejudicestill remain. Clearly, these extremely effective

medicines seem to need some explanation.

As they play an important part in

dermatology. the study of skin diseaseand

can be used in a variety of ways to soothe

and heal,there are many good reasons forclearing up these misunderstandings.


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2. A Look at the History of Corticosteroids

Before it became possible to produce this

substance artificially (to synthesize it), doctors

used natural extracts from the adrenal gland.

Then, during the 1950s, these new medicines

were used internally (systemically) for treating

rheumatism, and this new wonder drug

quickly went on to assert itself in dermatologyas a treatment for psoriasis and eczema. The

discovery of this substance, which is also very

effective when applied to the skin externally

(topically), is now recognized as a milestone in

dermatology, perhaps as significant as the

discovery of penicillin. And it was their

Cosmetically gratifying properties as much

as their dramatic medical effectiveness

that ensured the quick triumph of corticosteroids.Until their development, skin disorders could

only be treated with products that burn, stink, or

stain and they were often less effective.

As with many other medicines, it took time for

the medical industry to learn about the correct

use of the new drug. Certainly in the euphoria

of its initial discovery, too much was expected

of it, and its administration was not always

properlyregulated.

Although the first of these synthetically

produced hormones were very effective

against inflammations, they also had several

unwelcome side effects. One of the worst was

that when taken as a pill or when injected, they

often caused a softening of the bones

(osteoporosis)and water retention in connective

tissues. This swelling effect was sensationallyreported in the newspapers and on television;

with images of moon-faced people

plastered everywhere, cortisone became a

household word. On top of that, the extended

external use of creams or ointments would

often cause a thinning of the skin (atrophy).

Since then a great deal has changed, but the

results of research in this field have not always

been brought to the attention of the generalpublic. Scientists all over the world have

improved and modified the molecular structure

of corticosteroids and have created new variants

which means that since the 90s, the socalled

fourth generation corticosteroids have

been available for external application.

Today, corticosteroids are divided into four

strengths; therefore the appropriate strength

of medication can be found for almost allstagesfrom mild to severeof illnesses thatcan be treated with steroids.


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3. How Do Corticosteroids Work?

Regardless of their potency, stage of

development (first, second, third, or fourth

generation), and form of application (internal

or external), corticosteroids essentially functionin one of four different ways.


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Anti-Inflammatory Effect

Corticosteroids work especially well against

inflammation so that the typical symptoms of

redness, swelling, heat and pain, quicklydisappear. Above all, itching, a common

symptom of skin disorders, is quickly relieved

under the influence of corticosteroids. This is

important because if itching isnt relieved, a

vicious cycle of inflammation-itching-scratching-

inflammation will begin . The anti-inflammatory effect ofcorticosteroids is especially significant for rheumatism,

asthma and atopic eczema.


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Anti-Allergic Effect

An allergy is an oversensitive reaction by the

body to diverse substances. Certain foods,

pollen, metals, and latex can all trigger anallergy and hay fever, hives, (contact) eczema or

asthma will result.

These illnesses usually accompany an inflammation

of the affected organ (skin or mucous

membrane), and therefore corticosteroids can

be used very effectively.


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Immunomodulatory Effect

When the body has an especially strong reaction

to internal or external substances, the

symptoms are similar to those of an allergy.These defensive reactions are often positive

and necessary, but in some cases they are

unnecessarily strong or prolonged. Here,

corticosteroids work as modulators, minimizing

the effects of the reaction. A well known

example is that of patients who have an organtransplanted from a donor, and in this case, the

internal application (pill or injection) of corticosteroids

will help prevent the body from rejecting

the new organ.


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Anti-Proliferative Effect

Proliferation means cell division, and when

cell division is speeded up it is called hyperproliferation.

The hyper proliferation of skin cells(epidermal cells) is, for example, a particularly

violent symptom of psoriasis, and corticosteroids

can be used very effectively against

this increased cell division (which is often also

connected with an inflammation).

This broad range of effects is why corticosteroidsare used to treat such a variety of

symptoms and diseases.


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Corticosteroid Therapy:

1. When Are Corticosteroids Used?

2. Why Are Corticosteroids Used?

3. Treatment from the Outside4. Cream, Ointment or Fatty Ointmentthe Role of

Galenics


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1. When Are Corticosteroids Used?

Corticosteroids have a broad usage spectrum,

and therefore can be applied to a variety

of areas. Looking beyond their ability to

Alleviate skin disorders quickly and effectively,

Corticosteroids are also used against:

Rheumatic inflammations

Bronchial asthma

Kidney disease

Vascular and blood disorders

Intestinal and liver disorders

Nerve inflammation

Allergic shock

Post-organ transplant

Those who suffer from a sluggish adrenal

gland need to take a regular, constant dose of

corticosteroids because the production of

natural cortisones is disrupted. This disorder,

called Addisons disease, afflicted, for

example, the American ex-President John F.

Kennedy.

Skin disordersespecially all mild and moderate

disorderscan usually be treated by the

external application of corticosteroids in the

form of creams and ointments, etc. This has

several advantages. For example, the skin is

one of the few organs that can be treated

directly and easily, and so the medication, or

active ingredient, can be applied directly to the

affected area. Another advantage is that direct

application prevents the entire organism from

being affected, thereby avoiding possible

Side effects. If used correctly, it is almost

Impossible for systemic effects like increased

water retention or osteoporosis to occur as a

result of the topical application of corticosteroid


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Topical (external) All forms of eczema, even

atopic dermatitis

All forms of psoriasis Physical skin damage from

exposure

Sunburn

Other skin disorders

caused by disturbances

in the immune system

Areas for Applying

Corticosteroidsto Alleviate Skin Disorders

Areas for Applying

Corticosteroidsto Alleviate Skin Disorders

Systemic (internal) Serious forms of eczema

Serious allergies; e.g., hives

Serious psoriasis withextensive effects on skin

or joints

Other serious skin and

immune system disorders


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2.Why Are Corticosteroids Used?

Many skin disorders heal by themselves ifthe cause of the disorder is removed. However,

there are still many reasons to treat the

symptoms. First of all, symptoms like redness

and swelling are often very annoying and

sometimes even painful. It is completely

understandable that patients who suffer, for

example, from obvious disfigurements to their

face or hands will want to be free of these

symptoms as quickly as possible. Another

reason is that skin disorders are often accompanied

by itching. Excruciating itching is one

of the most unpleasant symptoms of skin

disorders, and it can disturb sleep and theability to concentrate, which in turn causes

mental strain. Moreover, many patients often

unconsciouslyalmost as a natural reflexwill

try to scratch away the itching, only adding

to the problem as the infection cannot heal and

new inflammation may occur, causing more

itching a vicious cycle that must be brokenas soon as possible!


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2.Why Are Corticosteroids Used?

(Continued.)

On the other hand, there are skin disorders

for which there are still no known cures, like

psoriasis, which is the result of a genetic

defect. Is treatment of psoriasis with cortisone,

then, a sham? Not at all! Here again, effective

therapy is required. The illness progresses in

phases during which there are times that the

patient is virtually free from symptoms, and

other times when the symptoms are very

strong. In this case, treatment is carefully

tailored to the patient and his or her lifestyle,so that the symptoms of each phase of the

disorder are kept well under control, thereby

significantly improving the quality of life. The

short-term use of corticosteroids can also

shorten the length of the acute phases.


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3.Treatment from the Outside

Skin disorders are normally treated from

the outside, with medication being applied,

in the form of creams or ointments, to the

skin. Actually, the effect is the same whether

the drugs are administered topically or

systemically. However, if a medication mustfirst pass through the stomach, intestines,

and/or bloodstream before arriving at its

destination, its long journey will take it

through the entire organism, increasing the

chance of unwanted medical side-effects

(see also Chapter I.2). By taking medicinethrough the skin (resorption), the chance of

side-effects is highly unlikely. Modern

corticosteroids

have dual protection mechanisms

that almost completely preclude an

unwanted impact on the organism.


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3.Treatment from the Outside

An ExampleThe corticosteroid Methylprednisolonaceponate

(MPA) can be applied to the skin as one

of five different preparations (from very greasy

to completely oil-free). As long as the active ingredient

is in the tube, however, it is not a

highly active medication. It is first activated to

its full potency by the inflammatory enzymesfound in the afflicted skin. This is what is called

a pro-drug. It also means that it cannot harm

healthy skin, even if it is spread outside the

afflicted area.

After this bio-activation, MPA will reach its full

potency and relieve the inflammation with

biochemical processes in both the cellular

core and the cellular membrane. Having doneits job, the active ingredientas with all other

medicinesis transported away in the bloodstream,

leaving the body by way of the

kidneys. However, the moment MPA enters the

body it bonds with glucuronic acid (a detoxifying

agent), which robs MPA of its specific corticosteroid

potency, thus preventing it fromcausing side-effects due to systemic activity.


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4.Cream or Ointmentthe Role

of Galenics

Skin disorders like atopic eczema (neurodermatitis)

or psoriasis run in phases; periods free of symptoms alternate with

periods when the disorder becomes acute, and clearly

visible, tangible signs appear on the skin. In the problem-free phases,

called remission, it is enough to care for the skin as you usually

would, according to the individual skin type. However, this care must

be consistent, and would include, for example, moisturizing the

skin carefully after every bath or shower. Patients can considerably

extend the periods without symptoms in this way!

Should the disorder recur (relapse), the medication

would usually need to be started again.

While using the right potency will make a difference (e.g., a stronger

or weaker corticosteroid), the different types of compounds that

transport the medicine are also important. In dermatology, these

compounds are called galenics and come in the form of creams,

ointments, milks, solutions, etc. The main differencebetween them is in the amount of water they contain.


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4.Cream or Ointmentthe Role of Galenics

(Continued..)

All of these different compounds can be

applied to very specific areas. This is important

because whether or not a fatty, low-fat, or

completely fat-free formula is required willdepend on the location of the afflicted patch of skin,

and the stage of the illness.


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Creams contain more water than fat. They are

therefore very pleasant to use (they dont leave

a film on the skin) and do not form a barrier

against perspiration. This means they can also

be used during acute inflammations, when theskin needs to be able to release moisture and

heat.

Creams


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Ointments have both water and relatively high

levels of fatty components. They are also

called

universal creams because they can be used

in many ways, and are particularly appropriatewhen the skin neither weeps, nor is chronically

altered.

Ointments


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Fatty ointments consist essentially of oils and

contain no water. They coat the skin with a film

through which neither water nor air can penetrate.

These compounds are used for very dry

chronic conditions. They ensure that the

medicine is very concentrated, that the skin is

prevented from drying-out further, and that oil

is replenished.

Fatty ointments


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When Doctors Prescribe

Corticosteroids

1.The Doctors Diagnosis and

Recommended Treatment

2.The Patients Co-operation

3.An Overview: the Most CommonUses of Corticosteroids


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1.The Doctors Diagnosis

and Recommended TreatmentLike many medications, corticosteroids

are prescription drugs, and with good

reason.

Thanks to their medical training and

experience, doctors are able to assess the

patients symptoms according to followingcriteria.

What is the disorder?

At which stage is it?

With which medications can

it be treated?

Is the application of corticosteroidsindicated?

Which concentration of the drug

is appropriate?

Which galenic should be used?

How often should the drug be

taken and for how long


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The success or failure of a treatment is not

the sole responsibility of the doctor. Quite theopposite. Particularly with skin disorders,

which are generally treated by the patient

over a long period of time, the patients trust

and co-operation are often deciding factors in

the success or failure of a treatment. Here are

a few of the most important considerations.

Length of Therapy

It is possible that the primary results of treatment

will been seen very quickly. However, thetreatment should not be discontinued without

the doctors consent because the inflammation

must be stopped completely.

Weaning

To prevent symptoms from recurringsometimes

recurring symptoms are even more

severe if the treatment stops suddenly

(rebound effect)patients should be tapered

off the medication gradually. In other words,over a period of a few days, the medication is

applied less often and in smaller doses, or with

a lower concentration.

Localization

Do not use a medicine that your doctor

prescribed for the backs of the knees on other

places like the face or groin. Active ingredients

and galenics are always specific to an area of

skin, and using them elsewhere can cause

unwanted side-effects.

2.The Patients Co-operation


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3.An Overview:

the Most Common Uses of CorticosteroidsAtopic Eczema (Neurodermatitis)

Atopic eczema or dermatitis, also known as

neurodermatitis, appears when the immune

system responds to various environmental

substances, and often, more aggressively, as

a symptom of mental strains such as stress.

This can result in eczema of varying degrees

afflicting the entire body, including the headand scalp. As a rule, though, only the backs of

the knees and insides of the elbows are

affected. Atopic eczema is a chronically recurring

disorder, i.e., acute stages alternate with

intervals of less inflammation or a complete

lack of symptoms. Even without acute eczema,

though, the skin is dry and irritable, so consistent

basic skincare is necessary.

Children are especially affected, sufferingparticularly from itching that doesnt let them

sleep at night or concentrate at school.1

Atopic eczema often fades as they get older,

although the skin usually remains dry and

sensitive. Patients with atopic eczema also

tend to react to allergens that cause hay fever,

which can later become asthma. This is

calledsomewhat harshlyan allergy career,

but can often be avoided with consistent care.


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Contact Eczema

Allergies to environmental reagents have

become much more common in recent years.

They are triggered by direct contact with a

specific substance, but generally disappear

once the cause is removed. Even so, a fast,effective therapy can be importantespecially for

painful inflammations and visible parts of the body. A

typical example is the chrome nickel-allergy which is

triggered by fashion jewellery. Body piercing, so

popular today, causes this kind of allergy more than

anything else (most of the complications from piercing

come less from allergens and more fromunprofessional and unhygienic work).


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Misunderstandings About Cortisone

1.The Ten Most Common Errors

2.The Package Insert


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1. The Ten Most Common Errors

A poll showed that there are still many

misunderstandings about corticosteroids,

mainly concerning their side-effects. These

concerns can cause misgivings leading to a

treatment not being followed, or being stopped

too soon, and can influence the patients

cooperation.The following are a few clarifications

of the most common misconceptions.

Cortisone is purely chemical.Cortisone is an anti-inflammatory hormone

that every human produces in the adrenal

gland. The artificial clones of cortisone, the

corticosteroids, have an indispensable placein the treatment of skin disorders. Corticosteroids

count among the best and most

important anti-inflammatory substances in

modern medicine.


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Cortisone makes you swell.These days, there is a low risk of side-effects

like weight gain or water retention from theexternal use of ointments and creams containing

corticosteroids. Modern corticosteroid

preparations work selectively; i.e., they are

activated on the area of the body that is

inflamed by the bodys own enzymes, and they

decompose after having taken effect. In

this way, healthy skin and the rest of the

organism is almost unaffected by todayssteroid therapies.

Cortisone thins the skin.Every doctor knows where the individual

problem areas of the skin are located. He

has access to a multitude of potent and

cosmetically pleasing compounds (ointments,

solutions, creams, milks) that can be adjustedprecisely so that they are absolutely appropriate

for the location and degree of the illness.

This prevents unwanted side-effects like

thinning skin. After the acute inflammation has

been relieved, treatment is gradually moved to

corticosteroid-free products (weaning). Side

effects

can result, however, if the patientattempts to diagnose and treat him or herself.

The Ten Most Common Errors


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Cortisone destroys bones.A weakening of the bones (osteoporosis) is

virtually impossible with external use of

corticosteroid preparations. Why? Modern

corticosteroids work selectively at the place of

inflammation and decompose immediately

after they take effect without unnecessarilytaxing the organism. Only the long-term,

internal use of high dosage corticosteroids can

lead to osteoporosis. The attending doctor will

carefully assess the risks of treatment in these

cases.

Cortisone damages internal organs.Again, external corticosteroid therapy is harmless

to internal organs. Modern corticosteroids

work selectively at the place of inflammation

and decompose immediately thereafter. The

healthy skin and organs remain unaffected.

The internal use of high dosage corticosteroids

(injections, pills) over a longer period of time,

though, could tax the system.



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Cortisone only helps short-term.No. Corticosteroids not only alleviate the acute

symptoms of a skin disease, they represent an

indispensable part of the entire healing process.

However, corticosteroid therapy should not be

stopped abruptly once the acute stage has

been relieved. Instead the patient should be

weaned off. This minimizes the risk of relapse.Also, even in cases of genetic skin disorders

that are not completely curable, corticosteroids

can alleviate the excruciating symptoms and

contribute to extending symptom-free phases.

Pill or ointment? Its all the same.

Yes and no. In principle, there is no differencein the working mechanism of corticosteroids

whether they are administered to the infected

cells as pills or as ointments. However, the risk

of side-effects is considerably less when they

are applied to the skin, rather than via the

bloodstream, because the rest of the organism

will remain unaffected.


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Cortisone is not intended for children.Wrong. The treatment of children with corticosteroid therapy is, as a rule,

less taxing than the illness itself. The selective, short-term use of

corticosteroids breaks the vicious cycle of inflammation, itching,

scratching and reinflammation and after just a few days the gradual shift

to corticosteroid-free products can begin. Today, even potent

corticosteroids are much better designed for use on children.

Cortisone is very harsh medicine.Corticosteroids are available in different concentrations. There are four

basic groups of corticosteroid potency: mild, moderately potent, potent,

and very potent. Doctors can choose the correct concentration to suit the

diagnosis, severity of the illness, and the patients individual preferences.

Treatment is specifically designed by the doctor to be as strong as

necessary, as gentle as possible.

Cortisone is prescribed too often.Medication is only ever administered when it is necessary. Doctors

carefully weigh its use against the possible risks. They only use

medicines as long as is necessary and as briefly as possible.

Corticosteroids are mainly prescribed for acute and especially severe

skin disorders.



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2.The Package Insert

Its always the same with almost every

prescription drug: you come home from the

pharmacy, unpack your medicine, glance at

the package insert, and are immediately put

off taking the drug because of the number of

side-effects listed. Some people dont read the

information at all; others study the package

insert very carefully and closely watch themselves

for signs of side-effects. What is the

truth about package inserts and the side effects

they describe?

Most local laws stipulate that before a medication

may be sold in the pharmacy it mustundergo several years of stringent testing.


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During testing, the following is documentedTherapeutic effects

(=potency, when healing begins, and

the duration of the healing process)

Side effects

(=unwanted medicinal effects)

Interactions

(=what happens when the drug is takensimultaneously with other medications)

This research shows

Indication

(=for which illnesses the medication

can be used)

Contraindication

(=when the medication may not

be used)

Dosage instructions

(=method, amount, and duration of

application)

Precautions

(=what to do in the case of anoverdose, etc.)


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Kashif Raees

SPO Derma South-2


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Documents

Corticosteroids , In the Treatment of Skin Disorders