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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

adverse effects of high dose systemic corticosteroids

  • 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

adverse effects of long term low to medium dose systemic corticosteroids

  • immune suppression and risk of infections
  • delayed wound healing
  • instability of diabetes, hyperglycaemia
  • 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)

usual doses

oral prednisolone

  • 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

IV dexamethasone

  • usual adult dose is 8mg IV per day

IV hydrocortisone

  • 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

topical corticosteroids

  • 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

general usage guidelines

  • 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

adverse effects

  • skin atrophy with possible scarring and ulceration
  • increased skin transparency and brightness
  • telangectasia
  • striae
  • easy bruising
  • delayed wound healing
  • faster spread of skin infections
  • hypopigmentation
  • glaucoma if used near the eye
  • contact hypersensitivity to preservatives
  • tachyphylaxis
  • systemic effects if extensive skin areas

classification based upon potency

super-potent - class 1 USA / UK

  • 0.05% betamethasone dipropionate as ointment in optimised vehicle
  • 0.05% clobetasol propionate

high potency - class 2/3 USA, class II UK

  • 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

moderate potency - class 4/5 USA, class III UK

  • 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

low potency

  • 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
corticosteroids.txt · Last modified: 2024/04/22 12:39 by gary1

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