EczemaNet Update

Treating Eczema with Steroids

Treatment with steroid-based corticosteroids can mean relief from the constant itching and accompanying red, scaly skin patches that result from eczema.

Yet, many patients and their families are fearful of using steroids due to potential side effects associated with the drugs. This fear, or “steroid-phobia,” among patients can be lessened by working with a dermatologist who is trained in prescribing these drugs, can monitor patients closely and incorporate creative treatment strategies to minimize side effects.

Eczema, a chronic disease in which the skin becomes itchy and inflamed, affects about 15 million Americans. One of the most common forms of eczema is atopic dermatitis, or AD, which can occur on just about any body part. AD takes a physical and emotional toll because it can be painful and physically unattractive, causing skin redness, swelling, cracking, weeping and scaling.

The majority of patients have a “mild” form of the disease, meaning the AD affects less than 20 percent of the body surface area. Still, left untreated, even the mild form can result in itching and rashes that become a significant and visible reminder of the disease. For people whose AD affects more than 20 percent of their bodies, the disease can be a physically painful problem.

Goals of treatment

One of the most important goals of eczema treatment is to prevent the development of rashes by avoiding those things that trigger itching. In the mildest form of the disease, simple moisturizers and cold compresses might help relieve and prevent the dry, itchy skin of eczema. However, experts note, once skin inflammation occurs, prevention is less effective and anti-inflammatory agents, such as corticosteroids, become necessary to effectively manage the condition.

It has been shown time and time again that the key to the safe and effective use of these agents is to use them under the watchful eye of a dermatologist experienced in prescribing them. Despite the potential side effects, studies have shown that severe side effects are rare when dermatologists prescribe long-term continuous low-potency corticosteroid treatment for up to 10 years, or intermittent mid-potency topical treatment for moderate to severe eczema. It is important that dermatologists carefully monitor patients using corticosteroids for any period of time. Another essential element of successful treatment is that patients consistently take or apply their medications as prescribed by their dermatologists.

Topical corticosteroids: types and uses

Corticosteroids, including nonprescription and prescription forms, are widely used in the treatment of eczema. This class of substances is related to a natural hormone that can diminish an inflammatory response. In particular, glucocorticosteroids (GCSs), which have been used since 1951 for a wide variety of inflammatory skin diseases, offer very effective anti-inflammatory properties.

For the treatment of mild to moderate inflammatory skin diseases, dermatologists usually first use topical GCS therapy, meaning patients apply the therapy to their skin. These preparations include less potent nonprescription and more potent prescription forms. Topical types of the medication can be delivered to the skin in many different forms including as an ointment, lotion, cream and foam.

The medications are classified according to their potency, or strength. Topical hydrocortisone, which is a low-potency GCS available in non-prescription and prescription forms, is used on areas of sensitive skin, such as the face or in the skin folds. Mid-potency GCSs, such as flurandrenolide and betamethasone dipropionate in lotion form, are prescribed by dermatologists and are appropriate for lesions on the torso. Prescription-only high-potency topical GCSs, such as fluocinonide, betamethasone dipropionate, in lotion, cream or ointment form, and clobetasol propionate, are reserved for short treatments of up to two weeks for stubborn lesions, as well as rashes on the palms of the hands or soles of the feet.

Dermatologists strive to use the mildest forms of topical medications possible in order to minimize potential side effects. However, they might use a higher-potency corticosteroid for a short period to address an acute situation; then continue with milder forms.

Dermatologists generally use the topical form of corticosteroids to treat atopic dermatitis rashes that do not have open or crusted sores. They might use the higher-strength preparations for tougher-to-treat thickened skin, and scaly or oozing rashes. The creams, lotions, ointments or foams are usually applied one to four times a day, depending on the patient’s age and the strength of the preparation.

Corticosteroid treatments usually significantly clear intermittent rashes in two to three days. Dermatologists might use topical corticosteroids for only a short time--until the rash is cleared. In general, intermittent treatment with high potency topical corticosteroids will last seven to 10 days; while low- to mid-strength corticosteroid treatment can last two to three weeks.

Oral/systemic corticosteroids: treatments of last resort

Dermatologists usually will not prescribe oral or injected (systemic) forms of corticosteroids unless the atopic dermatitis, or other chronic eczema, is severe or topical agents have not worked. Still, the oral medications have their places in treatment. For example, they are often effective in reducing inflammation and itching and a high initial dose can eliminate rashes quickly. In addition to recalcitrant severe chronic disease, oral/systemic steroids may be indicated to treat widespread acute eczema, such as severe allergic contact dermatitis to poison ivy. Systemic corticosteroids include: methylprednisolone, hydrocortisone, prednisone and prednisolone.

Potential side effects of corticosteroids

With all their promise, topical, oral and systemic GCSs have drawbacks. The literature reflects more than 50 years of studies noting a variety of adverse reactions to corticosteroids—ranging from mild to life-threatening and life-altering. The research has looked at side effects related to the dose and potency of the medications. Some side effects also are related to the drug’s method of administration—whether it is given orally or applied to the skin; length of therapy; patient’s age; and site of topical application.

GCS therapy’s side effects have been shown to include:

Osteoporosis, a loss of bone density or bone thinning can occur especially in women who take daily prednisone therapy for long-term periods.

Growth retardation is a side effect that occurs especially with long-term, systemic (oral or injected) administration of GCS before age two or at puberty. Experts say that children usually resume growing once GCS therapy is discontinued.

Cataracts, or a clouding of the eyes, is a known side effect of high GCS dosages and long-term topical therapy applied around the eyes.
Glaucoma, an eye disease, can result when GCS treatment is applied topically around the eyes or administered systemically, especially when patients are already at high risk for glaucoma.

Weight gain may occur because of increased appetite and fluid retention, which can begin after one month of taking larger doses of corticosteroids.

Hypertension, or high blood pressure, is most common in patients with preexisting hypertension who are on long-term, therapeutic doses of corticosteroids.

Gastrointestinal effects, such as nausea and vomiting, can occur with oral GCS therapy. Patients can minimize these effects by taking their medication with food. Peptic ulcers have also been shown to occur in patients taking nonsteroidal anti-inflammatory medications along with corticosteroids, as well as those with past histories of peptic ulcer disease, smoking or alcohol use.

Skin effects, including stretch marks and spider veins, occur not only with systemic GCS, but also with long-term use of potent topical agents. Sometimes, acne appears on the trunks of patients going through puberty, who are also on corticosteroids. Acne around the mouth has also been shown to occur with corticosteroid use when potent forms of the therapy are applied to the face.

Infection; skin rashes and irritation; skin thinning; blurred vision; formation of dilated blood vessels and stretch marks are other side effects that are often associated with the use of topical corticosteroids. To prevent these, dermatologists may limit the time that patients are on the topical agents or select less potent treatments for more sensitive areas of the body, such as the face.

Tachyphylaxis, or a decreasing response to corticosteroids, can occur with long-term use of the medications. This can be detected with careful monitoring of medication use.

Despite the side effects, topical and systemic corticosteroids remain important, effective eczema treatments. Experts say that when administered and carefully monitored by a dermatologist, corticosteroids generally control atopic dermatitis safely and effectively.

There are other options

Topical corticosteroids had been the mainstay of eczema treatment until the recent Food and Drug Administration approval of new steroid-free medications, called topical immunomodulators, or TIMs. TIMs have been shown in studies to effectively treat moderate to severe eczema, while avoiding side effects typically associated with steroid use.

The key to successful eczema treatment is for patients to talk with their dermatologist about treatment options. Together, dermatologists and patients can discuss the pros and cons of treatments to determine which regimen will offer patients a better quality of life and relief of the eczema with the fewest side effects.