- Steroid Side Effects: How to Reduce Drug Side Effects of Corticosteroids
- How to reduce drug side effects
- Understanding corticosteroid side effects
- What is eczema?
- What are topical steroids and how do they work?
- What types of topical steroids are there?
- When and how are topical steroids used?
- How do I apply topical steroids?
- Using topical steroids and moisturisers (emollients) together
- Are there any side-effects from topical steroids?
- Two common mistakes when using topical steroids
- Weight gain and changes in physical appearance
- Short-term steroid treatment
- How is it given?
- What are the potential side effects?
- What else should I be aware of?
- General advice on short-term steroid treatments
This quality improvement project aimed to increase the percentage of patients on LTOC with completed baseline monitoring to 100%. A quality improvement methodology using PDSA cycles as set out by the Institute for Healthcare Improvement.9
PDSA 1 (practice meeting): The initial intervention was to hold a practice meeting to inform the practice clinicians of the problem of steroid monitoring within the practice and work as a team to solve it. It was thought that after this meeting there may be a small increase in monitoring within the patient population, due to increase clinician awareness but that progress towards the project aim would be small. The study lost two participants at this point due to death, the number of patients in the study was now 20. Objectively, as expected, after the clinical meeting complete baseline monitoring of patients on LTOC increased very slightly from 18% to 20%. However, when looking at monitoring in general (measured as altered monitoring data in patients’ records in the previous 2 months), this increased from 36% to 55%. It is thought that this was due to increased awareness of the need to monitor LTOCs. Although this increase in monitoring was positive, it was not the full or correct monitoring that is, not all parameters were measured. Further change was then focused on the system in the hope of yielding more significant improvement (figure 3).
Baseline monitoring of long-term oral corticosteroids.
PDSA 2 (questionnaire): The second intervention was in the form of a questionnaire. Clinical staff were asked to answer questions regarding their knowledge of monitoring required for corticosteroids. This would assess the healthcare professionals’ knowledge of the subject but also assess their retention as it would be retested at a later date. It was thought knowledge would increase over time due to awareness and participation in this project. Initially, knowledge regarding LTOC monitoring among clinical staff (GPs, nurses and HCAs) was mixed. 37.5% of staff were able to identify four of the five components that should be monitored (BP, Wt, U&Es, TG, glucose).
37.5% of staff identified three components, while 25% of staff identified just two. The questionnaire was repeated 4 months after the initial clinical meeting. A slight alteration was made to the original question, changing from ’What should we monitor in people taking long-term high dose steroids?’ to ’What should we monitor (within the GP setting) in people taking long-term high dose steroids?’. It was hoped this would add clarity to the question. Knowledge was found to be at a similar level 4 months later. Twenty-eight per cent identified two components of LTOC monitoring, 28% identified three components and 42% identified four components. This suggests that staff knowledge at 4 months regarding monitoring of LTOC is largely unaltered by having a clinical meeting in itself as well as carrying out a QI project. Ideally, the same healthcare professionals would have been surveyed in the follow-up questionnaire; however, this was challenging from a practical point of view without allowing preparatory ’study’. Retention would likely have been improved had staff received training on LTOC. This did not occur to organisational difficulties and time constraints but would definitely have been of significant value.
PDSA 3 (steroid protocol): As a team, the practice decided that there was need for a protocol to be created for patients starting on LTOC. This would contain accurate medical guidance but also practical steps relevant within the setting of general practice. This was then created based on the NICE guidelines and shared with one GP. It was then circulated to the practice team electronically. The first GP provided critical feedback; however, feedback from the wider team was limited, from only one other GP. A key discussion point on the protocol focused on the need for bone monitoring patients on LTOC. Reviewing NICE guidance on osteoporosis, it cites Scottish Intercollegiate Guidelines Network (SIGN) guideline 142 (Management of Osteoporosis and the Prevention of Fragility Fractures) which suggest people on LTOC should be on bone protection medications due to the high risk of fractures associated with corticosteroid medication.10 Therefore, it was decided that patients did not need bone scanning as long as they were taking bone protection medications. If done again, it may have been more advantageous to share the new protocol in person at a practice meeting as this may have yielded greater feedback from a larger and more diverse group of stakeholders. As part further research, there would be value in assessing compliance to this new protocol.
PDSA 4 (patient information leaflet): As part of creating a staff protocol for the use of LTOC, it was suggested that this should include a patient information leaflet. Before creating a new leaflet, it was sensible to identify any pre-existing leaflets that may already exist. One such leaflet was available from the web-based ’patient’, commonly used by the practice for patient information leaflets. A further advantage is that these leaflets (from ’patient’) are already embedded within the patient record system, thus allowing easy access for clinicians. The information leaflet was reviewed with one GP and was approved for use within the staff protocol. In hindsight, it may have been more thorough to share the patient information leaflet with other members of the healthcare team. Creating a unique, to the practice, patient information leaflet may have produced a higher quality of leaflet but again time was restrictive due to other clinical work undertaken by the authors.
PDSA 5 (drafting a patient letter): A letter was chosen as the most appropriate method to invite a patient to attend for blood tests followed by a GP appointment 1 week later to review their results. A letter must include relevant information and be approved by both clinical and administrative staff. The letter was drafted using a patient letter template from within the practice. It was first discussed with a GP who approved it and then shared in person at an admin team meeting. Thankfully, at this point it was noted that the letter did not include the requirement to fast before the blood tests—vital for the accuracy of TG measurement. If repeated it would be wise to review the blood testing requirements prior to drafting the letter.
PDSA 6 (sending letters): Letters were sent to patients asking them to attend for blood tests followed by a review with a GP of their results. The question: ’Does providing patients with written communication increase LTOC monitoring within the practice?’ It was hypothesised that the letters would greatly increase monitoring. This was the case with complete baseline monitoring increasing from 20% to 60%. Twenty per cent received incomplete monitoring due to absent BP and/or Wt measurements. On the other hand, 20% of patients did not attend for monitoring. The letter was updated to inform patients that their Wt and BP should be checked. If this project was repeated, it would sensible to have sent the letters to a small sample of the patients within the study. This may have allowed the letter to be improved earlier. It is also noted that despite a protocol for new patients starting LTOC being created, no protocol for the HCA-led clinic itself existed. This will likely have contributed to lower complete baseline monitoring (figure 3).
PDSA 7 (GP review): 80% of patients attended for blood tests following a letter. The letter also instructed them that they were to have review with a GP with the results. The question: ’Does written communication increase steroid reviews among patients on LTOC?’ 70% of all patients on LTOC had review of their LTOC treatment with a GP following the steroid letter. Twenty per cent of patients did not have a review of blood results with a GP and 10% of patients did not attend for blood tests or a GP review following the steroid letter. Within the 70% who attended for GP review, 20% had not had a previous review of their LTOC since the start of the project (4 months). In hindsight, it may have been pertinent to ensure that both an appointment with the GP and HCA were booked at the same time. This is the process now. Some patients may have only expected to have a review with a GP if blood tests were abnormal (figure 4).
Percentage of patients attending for GP steroid review following steroid letter. GP, general practitioner; LTOC, long-term oral corticosteroids.
PDSA 8 (’pop-up’ reminders): Following lower than anticipated Wt and BP monitoring, it was discussed within the team the value of adding a ’pop-up’ message to patient records. This would remind the attending clinician that the patient was due to have these parameters measured. However, it was decided that this would be ineffective. Many patients have such ’pop-ups’ and thoughts among GPs that they are mostly ignored. Therefore, it is assumed that using ’pop-up’ messages would not yield greater monitoring. Further quality improvement projects could study the value of these ’pop-ups’.
PDSA 9 (clinic protocol): In evaluation of the project, qualitative research was carried out to gain the views of the HCAs involved in monitoring. Overall reaction to the project was positive with HCAs feeling appointments were ’as normal’. However, staff suggested that a ’clinic flow diagram’ would be useful so that ’every knows what they are doing’ and that ‘everybody is doing the same thing’. It was also advocated that appointment times would need to be doubled in order to carry out Wt and BP measurements with HCAs noting ’difficulty bleeding fasting patients’ and that ’anomalies may occur due to “busy-ness” ‘. A draft clinical was shared and approved by HCAs and is now in use. In hindsight, this would have been a valuable exercise to carry out at the start of the project.
PDSA 10 (sustainability): Also as part of evaluation qualitative research was undertaken with the practice manager. The hope of this was to achieve a sustainable model for the future in terms of monitoring patients on LTOC. It was identified that no recall system existed to identify these patients again and thus monitor them. To counteract this, an audit has been placed in the ’audit calendar’ and will now take place annually. This audit will identify patients tagged with the read code ’prolonged corticosteroid therapy’ and patients without a read code who have been prescribed >5 mg of oral prednisolone for >1 month. This was deemed sustainable as it was ’similar to other medication monitoring’ and ’within existing competencies and systems’. Again, in hindsight, it would have been beneficial to set up this project in the ’audit calendar’ at the start of the project.
Steroid Side Effects: How to Reduce Drug Side Effects of Corticosteroids
How to reduce drug side effects
How to think about the suggestions below: Any suggestion here which is not clear or which you think may not apply to you should be discussed with the your physician. Note also that the side effects of steroids very much depend on the dose and how long they are taken. If your dose is low, your risk of serious side effect is quite small, especially if precautions, as discussed below, are taken. Reading about these side effects may make you uncomfortable about taking steroids. You should be well aware of the risks before starting these medications. However, please be reassured that many people take steroids with minor or no side effects. Please also remember that steroids are often extremely effective and can be life-saving. If any of the suggestions here is unclear, or seems irrelevant to you, please discuss it with your physician.
Note: Which “steroids” are we talking about: The term “steroids” here refers to anti-inflammatory steroids (corticosteroids) such as prednisone and methylprednisolone (Medrol®) and dexamethasone (Decadron®). The information below does not refer to muscle-building or “androgenic” steroids (such as testosterone), which share some chemical similarities but function quite differently than anti-inflammatory steroids.
Understanding corticosteroid side effects
With long-term use, corticosteroids can result in any of the following side effects. However, taking care of yourself as discussed below may reduce the risks.
Increased doses needed for physical stress
Steroid use for over two weeks can decrease the ability of your body to respond to physical stress. A higher dose of steroid may be needed at times of major stress, such as surgery or very extensive dental work or serious infection. This could be needed for as long as a year after you have stopped steroids.
- Discuss this possibility with the surgeon or dentist, etc. who is taking care of you at the time. Your physician or surgeon may not feel you need to take the extra steroid at the time of surgery, but if they know you have been on corticosteroids they can watch you more carefully after surgery.
Steroid withdrawal syndrome
Rapid withdrawal of steroids may cause a syndrome that could include fatigue, joint pain, muscle stiffness, muscle tenderness, or fever. These symptoms could be hard to separate from those of your underlying disease.
If you get symptoms like these when you taper your steroids, discuss them with the doctor. Your physician will work with you to continually try to taper your steroid dose, at a safe rate of decrease, depending on how you are doing. On each visit, discuss with the physician whether it is possible to decrease your steroid dose.
Note that even if you are having a steroid side effect, however, steroids still must be tapered slowly.
When used for less than two weeks, more rapid tapering of steroids is generally possible.
Long-term steroids can suppress the protective role of your immune system and increase your risk of infection.
- Since steroids can decrease your immunity to infection, you should have a yearly flu shot as long as you are on steroids. If you are on steroids for a prolonged period of time, you should also discuss with your doctor the possibility of getting “Pneumovax,” a vaccination against a certain type of pneumonia as well as “Prevnar 13,” another pneumonia vaccine. Shingles vaccination (Shingrix®) may also be considered. Your physician will take your age and risk factors into account when deciding which vaccinations you need.
- Signs of possible infection, such as high fever, productive cough, pain while passing urine, or large “boils” on the skin should have prompt medical attention. If you have a history of tuberculosis, exposure to tuberculosis, or a positive skin test for tuberculosis, report this to your doctor.
Steroids may increase your risk of developing ulcers or gastrointestinal bleeding, especially if you take these medications along with non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or aspirin. If at all possible, don’t combine steroids with NSAIDs. If you are on low-dose aspirin for heart protection, your physician may want you to continue this when you take the prednisone, but might consdier adding a medication for stomach protection during the course of steroids.
- Report to your physician any severe, persisting abdominal pain or black, tarry stools.
- Take the steroid mediation after a full meal or with antacids, as this may help reduce irritation of the stomach. Steroids can increase your appetite.
Steroid therapy can cause thinning of the bones (osteopenia and osteoporosis), and increase the risk of bone fractures. At the beginning or before your steroid therapy, many patients will be asked to have a bone density test, especially if the steroid dose is high. If density is low, the bone density study It will be repeated in the future to assess the effectiveness of measures you will be using to prevent bone loss. Preventative strategies are important: a person can lose 10% to 20% bone mass within the first six months of corticosteroid therapy.
- Most people taking corticosteroids will need to take a calcium supplement unless they can get enough calcium from their diet (if you can get it from your diet, that’s the best option). See this reference from the National Institutes of Health about how much calcium you need for your sex and age, and how to get as much as possible from diet.
- The minimal daily requirement of vitamin D is 800 international units (UI) daily, and most people on corticosteroids should take this amount. Your physician may check your vitamin D level and see if you actually need a higher dose.
- Smoking and alcohol increase the risk of osteoporosis, so limiting these is helpful.
- Weight-bearing exercise (walking, running, dancing, etc) is helpful in stabilizing bone mass.
- People on corticosteroids who have low bone density may be put on medications such as alendronate (Fosamax®) or Prolia®, and there are a number of others.
- Assess risk of falls. Make a thorough examination of your home and correct situations that might result in a fall, such as eliminating scatter rugs and any obstacles between bedroom and bathroom, and installing night lights.
Steroids affect your metabolism and how your body deposits fat. This can increase your appetite, leading to weight gain, and in particular lead to extra deposits of fat in your abdomen.
- Watch your calories and exercise regularly to try to prevent excessive weight gain. But don’t let weight gain damage your self-esteem. Know that the weight will be easier to take off in the six months to a year after you discontinue steroids.
Steroids may impair your ability to fall asleep, especially when they are taken in the evening.
- If possible, the physician will try to have you take your entire daily dose in the morning. This may help you sleep better at night (evening doses sometimes make it difficult to fall asleep).
Steroids, especially in doses over 30 milligrams per day, can affect your mood. Some people can feel depressed, some extremely “up” without any apparent reason. Just being aware that steroids can do this sometimes makes it less of a problem. Sometimes, this side effect requires that the steroid dosage be decreased. When the steroids are absolutely necessary, sometimes another medication can be added to help with the mood problem. Make sure your family knows about this possible side effect.
- Simply being aware that steroids can have an effect on your mood can sometimes make it less of a problem. But, at times, this side will require that the steroid dosage be decreased. If maintaining the same steroid dosage is absolutely necessary, sometimes another medication can be added to help with the mood problem.
- Make sure your family and friends know about this possible side effect so they will know what’s going on if you respond to them in unexpected ways. Ideally, tell your family and friends about this possible side effect as you start the medication, so that they can help you detect any changes in your behavior.
Fluid retention and elevated blood pressure
Because cortisone is involved in regulating the body’s balance of water, sodium, and other electrolytes, using these drugs can promote fluid retention and sometimes cause or worsen high blood pressure.
- Watch for swelling of your ankles, and report this to your doctor. Occasional patients benefit from diuretics (water pills). Low sodium diet helps reduce fluid accumulation and may help control blood pressure.
- Have your blood pressure monitored regularly while you are on steroids, especially if you have a history of high blood pressure. Steroids can raise blood pressure in some patients.
Elevated blood sugar
Since cortisone is involved in maintaining normal levels of glucose (sugar) in the blood, long-term use may lead to elevated blood sugar or even diabetes.
- Your blood sugar should be followed while you are on steroids, especially if you are a diabetic, since corticosteroids can raise blood sugar.
Steroids can sometimes cause cataracts or glaucoma (increased pressure in the eye).
- If you have a history of glaucoma or cataract follow up closely with the ophthalmologist while on steroids. If you develop any visual problems while on steroids, you will need to see the ophthalmologist. Temporarily blurred vision when you start corticosteroids is often not a serious problem, but ophthalmology evaluation should always be arranged if you experience other, new visual symptoms while taking steroids.
Atherosclerosis (hardening of the arteries)
It is possible that steroids may increase the rate of “hardening of the arteries,” which could increase the risk of heart disease. This risk is probably much more significant if steroids are taken for more than a year, and if taken in high dose.
- Low cholesterol diet may help. If you develop signs suggesting heart problem, such as chest pain, get medical attention quickly. Work with your physician to address any heart risks that can be modified, such as exercise, weight and cholesterol level.
- Steroids, particularly at higher doses for long periods of time, can sometimes lead to damage to bones, called aseptic necrosis (also known as osteonecrosis or avascular necrosis). This can happen in a number of joints, but the hip is the most common.
- Hip pain, especially if you have no known hip arthritis, could be an early sign of this damage. Report this to your doctor.
Theodore R. Fields, MD, FACP
Attending Physician, Hospital for Special Surgery
Professor of Clinical Medicine, Weill Cornell Medical College
What is eczema?
The terms eczema and dermatitis mean much the same. That is, an inflammation of the skin. It causes red, itchy skin which may also blister. There are two main types of dermatitis/eczema:
- Atopic eczema. This is caused by a problem from within the body. If you have atopic eczema you are born with a tendency for your skin to become inflamed. Various parts of the skin tend to flare up with inflammation from time to time, usually on both sides of your body.
- Contact dermatitis. This is caused by a substance from outside the body. This typically causes patches of inflammation on areas of skin which have come into contact with the substance. If you avoid the offending substance, the skin inflammation should go away.
See the separate leaflet called Atopic Eczema and one called Contact Dermatitis which provide a general overview of the conditions.
Book a pharmacy appointment today
Did you know steroid creams for dermatitis are available from your local pharmacist? Book a consultation today.
What are topical steroids and how do they work?
Topical steroids are creams, ointments and lotions which contain steroid medicines. Topical steroids work by reducing inflammation in the skin. They are used for various skin conditions, including eczema. (Steroid medicines that reduce inflammation are sometimes called corticosteroids. They are very different to the anabolic steroids which are used by some bodybuilders and athletes.)
What types of topical steroids are there?
There are many types and brands of topical steroid. However, they are generally grouped into four categories depending on their strength – mild, moderately potent, potent and very potent. (Potent just means ‘strong’, but doctors tend to use the word potent.) There are various brands and types in each category. For example, hydrocortisone cream 1% is a commonly used steroid cream and is classed as a mild topical steroid. The greater the strength (potency), the more effect it has on reducing inflammation but the greater the risk of side-effects with continued use.
Creams (which are usually white) are usually best to treat moist or weeping areas of skin. Ointments (which are clear, rather than white) are usually best to treat areas of skin which are dry or thickened. Lotions (which are like thin creams) may be useful to treat hairy areas such as the scalp.
Dr Sarah Jarvis MBE
When and how are topical steroids used?
As a rule, a course of topical steroid is used when one or more patches of eczema flare up. The aim of treatment is to clear the flare-up and then to stop the steroid treatment.
It is common practice to use the lowest-strength topical steroid which clears the flare-up. So, for example, hydrocortisone 1% is often used, especially when treating children. This often works well. If there is no improvement after 3-7 days, a stronger topical steroid is usually then prescribed. For severe flare-ups a very strong topical steroid may be prescribed from the outset.
Sometimes two or more preparations of different strengths are used at the same time. For example, a mild steroid for the face and a moderately strong steroid for eczema on the thicker skin of the arms or legs. A very strong topical steroid is often needed for eczema on the palms and soles of the feet of adults because these areas have thick skin.
You should use topical steroids until the flare-up has completely gone and then stop using them. In many cases, a course of treatment for 7-14 days is enough to clear a flare-up of eczema. In some cases, a longer course is needed.
Many people with eczema require a course of topical steroids every now and then to clear a flare-up. The frequency of flare-ups and the number of times a course of topical steroids is needed vary greatly from person to person.
After you finish a course of topical steroid, continue to use moisturisers (emollients) every day to help prevent a further flare-up. See the separate leaflet called Moisturisers for Eczema (Emollients) for more details.
Short bursts of high-strength steroid as an alternative
For adults, a short course (usually three days) of a strong topical steroid may be an option to treat a mild-to-moderate flare-up of eczema. A strong topical steroid often works quicker than a mild one. (This is in contrast to the traditional method of using the lowest strength wherever possible. However, studies have shown that using a high strength for a short period can be more convenient and is thought to be safe.)
Short-duration treatment to prevent flare-ups (weekend therapy)
Some people have frequent flare-ups of eczema. For example, a flare-up may subside well with topical steroid therapy. Then, within a few weeks, a flare-up returns. In this situation, one option that might help is to apply steroid cream on the usual sites of flare-ups for two days every week. This is often called weekend therapy. This aims to prevent a flare-up from occurring. In the long run, it can mean that the total amount of topical steroid used is less than if each flare-up were treated as and when it occurred. You may wish to discuss this option with your doctor.
How do I apply topical steroids?
Topical steroids are usually applied once a day (sometimes twice a day – your doctor will advise). Gently rub a small amount (see ‘Getting the dose right – the fingertip unit’, below) on to areas of skin which are inflamed. (This is different to moisturisers (emollients) which should be applied liberally all over.) Gently rub the cream or ointment into the skin until it has disappeared. Then wash your hands (unless your hands are the treated area).
Getting the dose right – the fingertip unit
The amount of topical steroid that you should apply is commonly measured by fingertip units (FTUs). One FTU is the amount of topical steroid that is squeezed out from a standard tube along an adult’s fingertip. (This assumes the tube has a standard 5 mm nozzle.) A fingertip is from the very end of the finger to the first crease in the finger.
One FTU is enough to treat an area of skin twice the size of the flat of an adult’s hand with the fingers together.
Two FTUs are about the same as 1 g of topical steroid. For example, say you treat an area of skin the size of eight adult hands. You will need four FTUs for each dose. (This is 2 g per dose. So if the dose is once a day, a 30 g tube should last for about 15 days of treatment.)
The following are further examples:
|Area of skin to be treated (adults)||Size is roughly||FTUs each
|A hand and fingers (front and back)||About 2 adult hands||1 FTU|
|Front of chest and abdomen||About 14 adult hands||7 FTUs|
|Back and buttocks||About 14 adult hands||7 FTUs|
|Face and neck||About 5 adult hands||2.5 FTUs|
|An entire arm and hand||About 8 adult hands||4 FTUs|
|An entire leg and foot||About 16 adult hands||8 FTUs|
Fingertip units and children
An FTU of cream or ointment is measured on an adult index finger before being rubbed on to a child. Again, one FTU is used to treat an area of skin on a child equivalent to twice the size of the flat of an adult’s hand with the fingers together. You can gauge the amount of topical steroid to use by using your (adult) hand to measure the amount of skin affected on the child. From this you can work out the amount of topical steroid to use.
The following gives a rough guide:
For a child aged 3-6 months
- Entire face and neck – 1 FTU.
- An entire arm and hand – 1 FTU.
- An entire leg and foot – 1.5 FTUs.
- The entire front of chest and tummy (abdomen) – 1 FTU.
- The entire back including buttocks – 1.5 FTUs.
For a child aged 1-2 years
- Entire face and neck – 1.5 FTUs.
- An entire arm and hand – 1.5 FTUs.
- An entire leg and foot – 2 FTUs.
- The entire front of chest and abdomen – 2 FTUs.
- The entire back including buttocks – 3 FTUs.
For a child aged 3-5 years
- Entire face and neck – 1.5 FTUs.
- An entire arm and hand – 2 FTUs.
- An entire leg and foot – 3 FTUs.
- The entire front of chest and abdomen – 3 FTUs.
- The entire back including buttocks – 3.5 FTUs.
For a child aged 6-10 years
- Entire face and neck – 2 FTUs.
- An entire arm and hand – 2.5 FTUs.
- An entire leg and foot – 4.5 FTUs.
- The entire front of chest and abdomen – 3.5 FTUs.
- The entire back including buttocks – 5 FTUs.
Using topical steroids and moisturisers (emollients) together
Most people with eczema will also use emollients. Emollients are different to topical steroids and should be used and applied in a different way. When using the two treatments, apply the emollient first. Then wait 10-15 minutes before applying a topical steroid. The emollient should be allowed to sink in (be absorbed) before a topical steroid is applied. The skin should be moist or slightly tacky, but not slippery, when applying the steroid.
Are there any side-effects from topical steroids?
Short courses of topical steroids (less than four weeks) are usually safe and cause no problems. Problems may develop if topical steroids are used for long periods, or if short courses of stronger steroids are repeated often. The main concern is if strong steroids are used on a long-term basis. Side-effects from mild topical steroids are uncommon.
Side-effects from topical steroids can either be local or systemic. Local means just affecting that bit of skin and systemic means affecting the whole person.
- A stinging or burning feeling when you first apply the treatment. This is quite common but improves as your skin gets used to the treatment.
- Thinning of the skin has always been considered a common problem. However, recent research suggests that this mainly occurs when high-strength steroids are used under airtight dressings. In normal regular use skin thinning is unlikely and, if it does occur, it often reverses when the topical steroid is stopped.
- With long-term use of topical steroid the skin may develop permanent stretch marks (striae), bruising, discolouration, or thin spidery blood vessels (telangiectasias).
- Topical steroids may trigger or worsen other skin disorders such as acne, rosacea and perioral dermatitis.
- Skin colour may change. This is more noticeable if you have dark skin.
- Hair may grow more on the area of skin being treated.
- Some people may develop an allergy to the contents of the treatment, such as any preservative used. This may irritate the skin being treated and make the inflammation worse.
- Some topical steroid gets through the skin and into the bloodstream. The amount is usually small and usually causes no problems unless strong topical steroids are used regularly on large areas of the skin. The main concern is with children who need frequent courses of strong topical steroids. The steroid can have an effect on growth. Therefore, children who need repeated courses of strong topical steroids should have their growth monitored.
- Fluid collection in the legs.
- High blood pressure.
- Bone damage (thinning).
- Cushing’s syndrome – this is a rare problem caused by high levels of a hormone (chemical messenger) in your blood. Symptoms include fast weight gain, skin thinning and changes to your mood.
A leaflet comes with each topical steroid and gives a full list of possible side-effects.
Two common mistakes when using topical steroids
Some people use too little
A common mistake is to be too cautious about topical steroids. Some parents undertreat their children’s eczema because of an unfounded fear of topical steroids. They may not apply the steroid as often as prescribed, or at the strength needed to clear the flare-up. This may actually lead to using more steroid in the long term, as the inflamed skin may never completely clear. So, you may end up applying a topical steroid on and off (perhaps every few days) for quite some time. The child may be distressed or uncomfortable for this period if the inflammation does not clear properly. A flare-up is more likely to clear fully if topical steroids are used correctly.
Some people use too much
Only use topical steroids for eczema as directed by your doctor. Some people continue to use topical steroids each day in the long term after the eczema has cleared to ‘keep the eczema away’. This is not normally needed. Some people with severe eczema may require continuous steroid treatment. However, this should be under the close supervision of a doctor. All people with eczema should use moisturisers (emollients) every day to help prevent further flare-ups of eczema.
Weight gain and changes in physical appearance
Weight and physical appearance
Description: corticosteroids are known to frequently cause weight gain in patients. This gain is is usually moderate, consisting of 1 to 2 kilograms of added mass. In addition, corticosteroids enlarge certain aspects of the face. A “moon face” can result, meaning a large forehead and a large chin appear during treatment, accompanied by larger cheeks. Other gains occur in the neck (“buffalo hump”) and around the waist. These anomalies are due to a redistribution of fat cells in the body (called lipodystrophy) and not because of water retention.
Frequency: an estimated two to three months after treatment, 40-60% of patients will observe significant change in their physical appearance, mainly cause by lipodystrophy. Only 10% will have a significant weight gain (>= 10% of their “usual” weight). Women, younger patients and overweight individuals appear to be more at risk. Moreover, the risk increases with a higher prescribed dose (e.g. the equivalent of 10 mg per day of prednisone or prednisolone)
Short-term treatment versus long-term treatment: these side effects occur early but usually become visible and bothersome after several weeks of treatment. With short-term treatment, these side effects are often not an issue for the patient.
Prevention/Treatment: diet appears to play a role in the development of these side effects. However, it is not the only factor. Your genetic history may predispose you to experience more or less side effects than other patients. In any case, a diet with less calories than normally consumed is recommended. Many doctors believe that a limitation of carbohydrate intake (e.g. sugars, bread) may be beneficial in decreasing the weight gain associated with cortisone use. However, this has never been proved nor demonstrated. Limiting your intake of salt hasn’t proved to be an effective counter-measure to weight gain and lipodystrophy. Once these side effects appear, there are no known effective treatments to stop their presence. Only a balanced diet and regular physical exercise can be recommended.
Reversibility: these side effects reverse themselves as soon as the corticosteroid therapy has been discontinued. Lipodystrophy could even begin to disappear as soon as the cortisone dose falls below 10 mg per day.
Good to know
- You should make sure you differentiate between weight gain caused by corticosteroids and the weight gain caused by the improvement of your illness under corticosteroids.
- Huscher D et al. Dose-related patterns of glucocorticoid-induced side effects. Ann Rheum Dis. 2009
- Curtis JR et al. Population-based assessment of adverse events associated with long-term glucocorticoid use. Arthritis Rheum. 2006
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Short-term steroid treatment
How is it given?
Steroids are taken by mouth, either as tablets or soluble tablets.
Alternatively, they are given into a vein (intravenously or IV) through a cannula, central venous catheter or implantable port.
What are the potential side effects?
- Changes in behaviour
Your child may become irritable and have mood swings, and even revert to earlier childhood behaviour, such as temper tantrums. While this is usually temporary, your doctor or nurse can offer advice and support.
- Weight gain
A potential increase in appetite means your child could feel hungrier and may eat more than usual, which can lead to weigh gain. A well-balanced diet may help. Increased fluid retention can also cause weight gain.
- Stomach lining irritation
Take steroid medicines with meals or after food to reduce stomach irritation.
Your child is unlikely to suffer many side effects if given a short course of steroids. Any they do encounter are temporary and will stop when the course is complete.
These side effects tend to occur only after long-term use or with high doses.
- Weight gain
Your child’s face may appear rounder than usual, particularly after long-term steroid treatment. If they’ve gained a lot of weight, your child may develop stretch marks, especially on their tummy and thighs.
- High blood pressure
Your child may complain of having a headache or feeling dizzy.
- Change in blood sugar levels
Steroids can cause a temporary increase in blood sugar levels. Look out for increased thirst and wanting to go to the toilet more often than usual.
- Effect on growth and/or thinning of bones
Your child’s growth could be affected by long-term use or high doses of steroid treatment and/or their bones may become thinner. We’ll monitor them closely throughout treatment to reduce the chance of these happening.
What else should I be aware of?
Steroids affect your child’s immune system, so they shouldn’t have any ‘live’ vaccines if they’re receiving a high dose of injected or oral steroids. But it’s important they’re up to date with other vaccines beforehand to avoid catching one of the diseases that vaccination prevents.
If you have other children, they should be also be up to date with their immunisations.
Although children are usually given the chicken pox vaccine, if your child is receiving high-dose steroids we recommend siblings or other close family members have it. Please ask your doctor for more information about immunisations.
If your child hasn’t had chicken pox, and is in direct contact with a child who has chicken pox, or develops it within 48 hours, contact the hospital immediately. Chicken pox can be more severe in children taking steroids. We’ll arrange for a blood test to check your child’s antibodies to chicken pox and your child may need an injection to protect them, but your doctor or nurse will talk through this with you.
If your child does have chicken pox, their steroid doses may need to be stopped. Your doctor will talk through this with you.
A child taking steroids is at an increased risk of infection. If they have a fever, or become unwell, contact your doctor or nurse.
Your child needs to be closely monitored while on steroid treatment, which may include checking their weight, blood pressure and urine. Your GP surgery, local hospital or local community nurses will usually run these check ups.
General advice on short-term steroid treatments
- If your child is on steroids for more than two weeks, you’ll be given a steroid card. Show this card to any health care professional looking after your child
- If your child has been on steroids for more than a few weeks and becomes unwell after stopping treatment, or needs to have an operation, their natural production of steroids (which helps a child respond to a stressful situation) will be reduced. They may need a short course of steroids to cover this period
- Keep medicines in a safe place where children cannot reach them
- The medicines should be stored at room temperature
- Steroids are best taken at the same time each day with food (usually in the morning), as directed by the doctor, nurse or pharmacist. Children on twice-daily steroids may have difficulty in sleeping if they take their second dose too late in the evening, so make sure the dose is given by late afternoon
- Your doctor will reduce the dose gradually if your child is on a long course of steroids or taking high doses. When your child has finished the course, return any remaining tablets to the pharmacist. Don’t flush them down the toilet or throw them away
- If your child vomits after taking the dose, tell your doctor or nurse as your child may need to take another one. Don’t give them another dose without informing the doctor.
- Don’t give your child a double dose if you forget to give them their dose.