Steroids, and using them without fear

Steroid is a word covering entirely different classes of drug used in entirely different ways, and the resulting confusion causes real undertreatment.

The distinction that matters

Anabolic steroids, used to build muscle, are a different class from corticosteroids used medically, and share almost nothing except the name.

Within corticosteroids, the route determines the risk profile almost entirely.

Topical steroids applied to skin, inhaled steroids for airways, nasal steroids, eye drops, injected steroids into joints and oral or intravenous steroids taken systemically all have very different exposures and very different consequences.

The serious effects people fear are principally associated with prolonged systemic use.

Topical steroids

Where the fear does most damage.

Topical corticosteroids are the mainstay of eczema treatment and are used in short courses to control flares.

They come in potency classes from mild to very potent, prescribed according to the site and severity — mild for the face and flexures, stronger for thicker skin.

Studies of steroid phobia consistently find that a substantial proportion of patients and carers apply less than prescribed or avoid them entirely, resulting in prolonged uncontrolled inflammation.

Which is worse for the skin than the treatment: chronic inflammation causes thickening, infection and sleep disruption, and requires more steroid overall than early adequate treatment would have.

The fingertip unit is the standard measure of how much to apply, and most people under-apply substantially.

Genuine adverse effects — skin thinning, stretch marks, telangiectasia — are associated with prolonged use of potent preparations on thin skin, particularly under occlusion, and are uncommon with appropriate use.

Topical steroid withdrawal is a described phenomenon associated with prolonged inappropriate use of potent steroids, particularly on the face, and is not a reason to avoid appropriate short courses.

Inhaled and nasal steroids

Where systemic absorption is low.

Inhaled corticosteroids are the foundation of asthma control and reduce exacerbations and deaths.

Local side effects — oral thrush and hoarseness — are reduced by using a spacer and rinsing the mouth afterwards.

Systemic effects are dose-related and generally small at standard doses, with growth effects in children being small and generally not affecting final height.

Nasal steroids are effective for allergic rhinitis and are among the more useful over-the-counter medicines, requiring consistent use over days to weeks rather than as needed.

Oral steroids

Where the significant risks sit.

Short courses for acute conditions — asthma exacerbations, croup, some inflammatory flares — are effective and generally well tolerated.

Prolonged use carries substantial risks: weight gain, diabetes, hypertension, osteoporosis, cataract, glaucoma, mood changes, infection risk, skin fragility and adrenal suppression.

Which is why long-term treatment involves bone protection, monitoring and efforts to use steroid-sparing agents.

Crucially, prolonged courses must not be stopped abruptly, since adrenal suppression means the body cannot produce its own cortisol immediately — which is why steroids are tapered and why anyone on long-term steroids should carry a card and know about sick-day rules.

Illness, surgery and injury increase requirements, and failure to increase the dose can produce adrenal crisis, which is a medical emergency.

Steroid injections

Into joints and soft tissue.

Effective for short-term pain relief in several conditions.

Evidence for longer-term benefit is limited, and repeated injections into the same site carry concerns about tendon and cartilage effects.

Which makes them useful as a means of enabling rehabilitation rather than as a treatment in themselves.

The practical rules

For anyone prescribed steroids.

Use the prescribed potency and quantity for topical preparations, and apply enough — undertreatment is the more common error.

Use a spacer and rinse the mouth with inhaled steroids.

Use nasal steroids consistently rather than intermittently.

Take oral steroids as directed and never stop a prolonged course abruptly.

Carry a steroid card if on long-term treatment and tell any clinician, including dentists.

Know sick-day rules if you have adrenal insufficiency or are on long-term steroids.

And ask what the plan is for stopping, since long-term prescriptions frequently continue by default.

The cost dimension

Worth noting.

Topical steroids and generic inhaled and nasal preparations are inexpensive.

The expensive consequence is uncontrolled disease: hospital admissions for asthma exacerbations, infected eczema requiring antibiotics, and the biologic agents used when conventional treatment has failed, which cost orders of magnitude more.

Which makes adequate use of cheap treatment the economical choice as well as the clinical one.

General information only, not medical advice. Consult a clinician or pharmacist about steroid treatment, and never stop long-term oral steroids abruptly.