Eczema with Steroids
steroid-based corticosteroids can mean relief from the constant
itching and accompanying red, scaly skin patches of eczema.
patients and their families are fearful of using steroids due to
potential side effects associated with the medications. This fear,
or “steroid-phobia,” among patients can be lessened by working with
a dermatologist who is trained in prescribing these medications, can
monitor patients closely, and knows how to 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.
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 may 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
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.
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
medication 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.
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.
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.
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 two times a day, depending on the
patient’s age and the strength of the preparation.
treatments usually significantly clear intermittent rashes in two to
three days. Dermatologists may 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.
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.
are not recommended for use during pregnancy due to studies that
show birth defects, such as cleft lip and cleft palate, may be
associated with the use of systemic corticosteroids during
Effects of Corticosteroids
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.
side effects have been shown to include:
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.
such as nausea and vomiting, can occur with oral GCS therapy.
Patients can minimize these effects by taking their medication with
food. Peptic ulcers also have been shown to occur in patients taking
non-steroidal anti-inflammatory medications along with
corticosteroids, as well as those with past histories of peptic
ulcer disease, smoking, or alcohol use.
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.
or high blood pressure, is most common in patients with preexisting
hypertension who are on long-term, therapeutic doses of
a loss of bone density or bone thinning, can occur especially in
women who take daily long-term prednisone therapy.
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 also are 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.
a decreasing response to corticosteroids,
can occur with long-term use of the medications. This can be
detected with careful monitoring of medication use.
may occur because of increased appetite and fluid retention, which
can begin after one month of taking larger doses of corticosteroids.
rashes and irritation; skin thinning;
of dilated blood vessels 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.
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.
corticosteroids continue to be the mainstay of eczema treatment.
However, two steroid-free topical medications, pimecrolimus and
tacrolimus, which belong to a class of drugs known as calcineurin
inhibitors, have been approved by the U.S. Food and Drug
Administration (FDA). These medications have been shown to
effectively treat mild to severe eczema, while avoiding side effects
typically associated with steroid use.
The key to successful eczema treatment
includes patients talking 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 from eczema with the
fewest side effects.
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