Systemic Steroids Corticosteroids

7/31/2019 Systemic Steroids Corticosteroids

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16/12 Systemic steroids (corticosteroids). DermNet NZ

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Facts about skin from the New Zealand Dermatological Society Incorporated.

Systemic steroidsSystemic steroids are also called corticosteroids, glucocorticoids or cortisones. They are synthetic derivatives o

the natural steroid, cortisol, which is produced by the adrenal glands. They are called systemic if the steroids

taken by mouth or given by intramuscular injection. Topical (cortico)steroids are applied directly to the skin.

Inhaled steroids are breathed in.

Systemic steroids include prednisone, prednisolone, methylprednisolone, beclamethasone, betamethasone,

dexamethasone, fludrocortisone, hydrocortisone and triamcinolone.

Systemic steroids work in the same way as natural cortisol, and are prescribed for a large number of serious

diseases. Skin conditions treated with steroids include blistering diseases such as pemphigus and pemphigoid

and severe forms ofdermatitis.

What is the role of natural corticosteroids?

Natural cortisol has important effects in the body, including regulation of:

Prote in, carbohydrate , lipid and nucleic acid metabolism

Inflammation and immune response

Distribution and excretion of water and solutes

Secretion of adrenocorticotrophic hormone (ACTH) from the pituitary gland.

What doses of systemic steroids are used?

Systemic steroids vary in strength. The beneficial effects as well as the side effects are proportional to the dotaken. Steroid dose is commonly characterised into:

Low dose (e.g. 20mg/day of prednis(ol)one, sometimes more than 100mg/day).

Treatment for less than one month is considered short term treatment. Treatment continuing for more than 3

months is regarded as long term, and results in the majority of undesirable side effects.

Corticosteroids for a few days or weeks are relatively safe, e.g. for acute dermatitis.

One must always carefully assess the severity of the underlying disorder, the gains that can be expected from

corticosteroid therapy, and the risks. Excessive corticosteroid use is one of the causes o fCushing syndrome.

Side effects from a short course of systemic steroids

If systemic steroids have been prescribed for one month or less , side effects are rarely serious. However the

following problems may arise:

Sleep disturbance

Increased appetite

Weight gain

Psychological effects, including increased or decreased energy

Rare but more worrisome side effects of a short course of corticosteroids include: mania, psychosis, heart failu

peptic ulceration, diabetes and aseptic necrosis of the hip.

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Side effects from a longer course of systemic steroids

Nearly everyone on systemic steroids for more than a month suffers from some adverse effects, depending on

daily dose and how long they have been on systemic steroids. These may include any of the following problem

which are not listed in any particular order of importance.

Skin problems

The skin is prone to the following adverse effects from prolonged courses or high doses of systemic steroids.

These may include:

Increased risk of skin infections such as bacterial infections (e.g. cellulitis) and fungal infections (e.g. tin

candida)

Skin thinning resulting in easy bruising (purpura), skin tearing after minor injury and s low healing; these

effects are most prominent on sun exposed areas particularly the backs of the hands and the forearms

Stretch marks (striae), particularly under the arms and in the groin.

Steroid acne: clusters of small spots on face, chest and upper back.

Excessive hair (hypertrichosis) and hair loss (alopecia)

Subcutaneous lipoatrophy (loss of fat under the skin surface) from injected steroid that does not go dee

enough into the muscle.

Moon face

Easy bruising

Skin thinning

Fragile skin

Acne

Stretch marks

Adverse effects of systemic steroids

Effects on body fat

Redistribution of body fat results in moon face, buffalo hump and truncal obesity.

Weight gain occurs in most patients on long-term steroids due to increased apetite and increased foodintake.

Effects on the eye

Glaucoma (increased intraocular pressure) can be due to corticosteroid eye drops as well as systemicsteroids; often there is a family history of the disease.

Posterior subcapsular cataracts in both eyes develop slowly; children are more susceptible than adults.

Swelling of eyelids and eye muscles resulting in bulging eyes (exophthalmos) is a rare side effect.

Central serous chorioretinopathy describes swelling within the eye resulting in separation of the choroi


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from the retina.

Vascular disease

Atherosclerosis (hardening of the arteries) in patients on long-term steroids may lead to:

Ischaemic heart disease: angina, heart attack (myocardial infarction), heart failure and atrial arrhythmia

Stroke (cerebrovascular accident, CVA) and transient ischaemic attack (TIA)

Increased all-cause mortality.

The effects of systemic steroids on atherosclerotic vascular disease may be due to complex metabolic changes

including:

Reduction in release of ACTH (adrenocorticotropic hormone) leading to elevated VLDL (very low densitylipoprotein), LDL (low density lipoprotein) cholesterol and triglycerides, and lower HDL (high dens itylipoprotein) cholesterol

Peripheral insulin resistance and hyperinsulinaemia

Gastrointestinal tract

Gastritis and peptic ulceration may be caused by corticosteroids.

Those also taking anti-inflammatory medications are at significantly increased risk of bleeding and shoutake acid-lowering medication to prevent this (e.g., a protein pump inhibitor such as omeprazole).

Systemic steroids may mask symptoms, so that patients sometimes first learn of gastrointestinal diseaswhen observing bleeding or when they become very ill from a perforation of the gut.

There is an increased risk of fatty liver (hepatic steatosis) on long-term steroids.

Fluid balance

Sodium and fluid retention cause leg swelling and weight increase, usually in those with underlying heaor kidney disease .

Increased blood pressure is common, especially with higher doses of steroid (more than 10mg ofprednis(ol)one daily).

Potassium loss may occur, causing general weakness.

Reproductive system

Effects of continuous use of corticosteroids include:

Irregular menstruation

Lowered fertility in men and women

Poss ible increased risk of cleft palate in offspring of women taking steroids in pregnancy

Musculoskeletal system

Osteoporosis (thinning of the bones) due to corticosteroids is common, particularly in smokers,postmenopausa l women, the elderly, those who are underwe ight or immobile, and patients with diabetor lung problems. Osteoporosis may result in fractures of the spine, ribs or hip joint with minimal traumaThese occur after the first year in 10-20% of patients treated with more than 7.5mg prednis(ol)one dailyis estimated that up to 50% of patients on long term oral corticosteroids will develop bone fractures.

Osteonecrosis (destruction of bones such as the hip) is an uncommon but serious risk of high doses ofsteroids.

Muscle weakness (myopathy) often affects shoulders and thighs.

Vertebral fractures are more common in patients on steroids, even in those with normal bone density.Steroids prescribed to children reduce growth, which may not catch up when the steroids are discontinuafter a prolonged course.

Nervous system

Psychological effects include mood changes, increased energy, excitement and euphoria.

Psychiatric symptoms are less common but include hypomania, psychosis, de lirium, memory loss anddepression, which may require assessment and treatment.

Insomnia and s leep distrurbance is more likely with split doses and tends to be less severe if a s ingle ddose taken in the morning.

Shakiness and tremor is more likely on higher doses.

Headaches are common but serious raised intracranial pressure is rare.


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Metabolic effects

During and after steroid treatment, the adrenal gland produces less of its own cortisol, resulting fromhypopituitary-pituitary-adrenal (HPA) axis suppression.

Steroids may result in higher blood sugar (glucose) levels in patients with diabetes mellitus.

Transient or persistent diabetes can affect previously nondiabetic patients, especially with higher dailydoses of steroids. This needs treatment.

Immune response

Glucocorticoids result in inhibition of innate and acquired immunity and affect T cells, B cells, phagocytes and

cytokines. This makes them effective in controlling a wide range of inflammatory diseases but also leads toadverse events.

Increased susceptibility to internal infections, especially when high doses are prescribed (e.g. tuberculo

Raised white cell count, especially due to an increase in circulating neutrophils

Reduced efficacy and increased risk of vaccines

Live vaccines such as polio or MMR (measles, mumps, rubella) should not be given to patients on higher doses

steroid (>20mg prednis(ol)one daily). It is safe and advisable to have other routine immunisations such as ann

influenza vaccination.

Effects of reducing steroid dose

Side effects from reducing the dose include:

Tiredness

Headaches

Muscle and joint aches

Depression

The lack of steroid response to stress such as infection or trauma could result in severe illness for up to twelv

months after the steroids are stopped.

Monitoring during steroid treatment

If you have been prescribed systemic steroids, make sure you understand how to take the medicine safely.Regular monitoring during treatment may include:

Blood pressure

Body weight

Blood sugar

Discuss any side effects you may experience with your doctor.

Prevention of osteoporosis

Specific measures to reduce the chance of steroid-induced osteoporosis should be considered for patients tha

have taken or are expected to take 10 mg or more of prednis(ol)one or prednisolone each day for a period of

three months or longer.

A DEXA bone scan measures bone density. Bone density gives an indication of the risk of fracture due to bone

loss. Arrange to have a scan as you start systemic steroids, and it should be repeated every year or as

recommended by your physician.

Preventative treatment includes the following medications:

Adequate dietary intake or calcium tablets up to a daily intake of 1200mg calcium per day

Vitamin D in various forms including monthly cholecalciferol 50,000 units (1.25 mg)

Oestrogen i.e. hormone replacement tablets in females that have had early menopause

Bisphosphonates (alendronate, etidronate, zolidronic acid); these are prescribed for patients at especiahigh risk of fracture.


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Treatment is most effective when started at the same time as the steroids, as most bone loss occurs w ithin th

first few months. This is most important for people taking more than 7.5mg of prednis(ol)one (or the equivalen

dose of another oral corticosteroid) for three months or longer.

If you smoke, stop. Consume minimal alcohol. Take regular weight bearing exercise e.g. walking for 30 to 60

minutes each day.

Reducing the dose of systemic steroids

Do not suddenly stop systemic steroids; your doctor will explain how to gradually come off them (particularlyimportant if you have been on them for more than six weeks).

No tapering is necessary if the course of steroids has been for less than one week.

After taking a dose of 30 mg or more per day for 3-4 weeks, reduce the dose by 10 mg or less per day,taking days to weeks to stop altogether.

A much slower reduction in dose may be required if the medication has been taken for several months olonger.

Alternate day dosing may reduce side effects.

Related information

On DermNet NZ:

Cushing syndromeTopical steroids

Intralesional steroids

Other websites:

Consumer medicine information Medsafe

Medicine data sheets Medsafe

Drugs, Herbs and Supplements MedlinePlus

Medsafe on osteoporosis due to systemic steroids

Oral Corticosteroids British Association of Dermatologists

Books about skin diseases:

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If you have any concerns with your skin or its treatment, see a dermatologist for advice.

Created 1997. Last updated 03 Mar 2012 . 2012 NZDSI. You may copy for personal use only. Please refer to our

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Systemic Steroids Corticosteroids