corticosteroids

also known as glucocorticosteroids

systemic corticosteroids

corticosteroids may cause a potentially fatal hyperinfection or disseminated strongyloidiasis in those who have lived in the tropics and have possibly undiagnosed chronic infection
- it is a helminth that is endemic to tropical and subtropical regions of the world, across Central and South America, sub-Saharan Africa, northern Australia and Asia
- preferably exclude strongyloidiasis (serum IgG levels for Strongyloides) prior to starting steroids or other immunosuppressants
- alternatively, commence ivermectin 200ug/kg daily for 2 weeks (ivermectin does not kill the strongyloides larvae only the adult worms hence need for repeat dosing at 2 weeks) and seek expert advice if the strongyloidiasis test comes back positive
- NB. strongyloidiasis can mimic asthma

leukocytosis which may cause a false suggestion of underlying infection
immune suppression and risk of infections
- do not give a live vaccine if considered immunocompromised!
- patients are generally considered immunocompromised from steroids if either:
  - short or long term daily or alternating daily doses of prednisolone > 20mg or equivalent, or,
  - less than 1 month after ceasing a prolonged course of high dose steroids (eg > 20mg prednisolone for more than 2 weeks)
- patients with the following are generally regarded as being immunocompetent if:
  - lower doses than the above
  - inhaled steroids
  - steroid injections eg i/articular
  - physiologic maintenance doses
delayed wound healing
instability of diabetes, hyperglycaemia
neurocognitive effects - may cause delirium or psychosis
longer term use or very high doses are associated with risk of spontaneous avascular bone necrosis (osteonecrosis / avascular necrosis bone (AVN)) eg. hip or knee
adreno-cortical axis suppression - risk of Addisonian crisis on sudden cessation hence need for weaning doses if more than 3 day course
hypokalemic alkalosis
vertigo
gastritis

immune suppression and risk of infections
delayed wound healing
instability of diabetes, hyperglycaemia
osteoporosis
osteonecrosis / avascular necrosis bone (AVN) - cumulative dose appears to be important risk
adreno-cortical axis suppression
thinning of skin
easy bruising, epistaxis
acne
Cushingoid effects
male-pattern hair growth in females
glaucoma, cataracts
depression, delirium
gastritis
myopathy
cardiomyopathy
reactivation of latent tuberculosis (TB)

come in 5mg and 25mg tablets or a liquid formulation for children
usual initial children's dose is 0.5-2mg/kg/day to max. 25-50mg/d
usual initial adult dose 25-50mg/day
- dose may be much higher for some conditions such as initial Mx of multiple sclerosis (MS)

usual adult and childrens dose is:
- 1-2 mg/kg (max. 250mg) intravenously (IV) every 6 hours initially for 24 hours;
- maintenance: 0.5-1 mg/kg every 6 hours

AVOID high potency or super-potent preparations on areas of thin skin such as the face, flexures, scrotum and eyelids
Take great care when using in occlusive dressings, in children (do not use on nappy region as occluded dressing) and, in the elderly
Should NOT be used on denuded skin
AVOID long periods of Rx - no longer than 2 wks on the face and 3-4 wks elsewhere - longer treatments should have steroid-free breaks of a few days to a week to reduce tachphylaxis.
Should NOT be used for infected skin, acne rosacea, acne vulgaris or perioral dermatitis
AVOID more than 45g/week of potent or more than 100g/wk of moderately potent steroid to minimise systemic effects in adults.
AVOID potent steroids in pregnancy as systemic absorption may cause fetal abnormality in animal studies
Most applications can be daily or bd, but where it is wiped off, may require more frequent applications

lotions are preferred for children (as more permeable skin), on hairy skin and for extensive areas but require shaking
creams are less greasy than ointments, easy to spread and washable in water
ointments provide the highest drug penetration and increase the potency
whole body application requires 30-40g per application!
one hand application requires 0.3g per application

0.05% betamethasone dipropionate ointment
0.1% betamethasone valerate ointment
0.1% mometasone furoate ointment or cream
the best option for chronic, hyperkeratotic, lichenified or indurated lesions such as:
- palmo-plantar psoriasis
- lichen planus
- lichen simplex chronicus

0.05% betamethasone dipropionate cream or lotion
0.05% betamethasone valerate ointment or cream
0.1% triamcinolone acetonide cream
0.1% methylprednisolone aceponate ointment, cream or lotion
0.05% clobetasone cream
the best option for:
- psoriasis other than intertriginous
- adult atopic dermatitis
- nummular eczema

0.5% or 1% hydrocortisone or hydrocortisone acetate
0.05% desonide
the best option for areas of thin skin such as:
- children's atopic dermatitis
- seborrheic dermatitis
- intertriginous psoriasis
- other intertrigos