What Are Systemic Corticosteroids?

Systemic corticosteroids are medications that may be used to treat severe atopic dermatitis (AD). They are a type of immunomodulator, drugs that suppress or interfere with the immune system response. The American Academy of Dermatology (AAD) states that immunomodulators are recommended for adult and pediatric patients whose disease is not controlled through the use of emollients, topical therapies, and/or phototherapy, as well as those patients whose medical, physical, or psychological states are greatly affected by their skin disease. In addition, the AAD cautions that systemic corticosteroids should be avoided if possible because of potential side effects, and the use of systemic corticosteroids should be reserved for severe exacerbations and for short-term use.1,2

How systemic corticosteroids work

Corticosteroids, also called steroids, mimic the natural corticosteroids produced by the adrenal gland. Some corticosteroids are used in topical formulations that are applied to specific areas of skin affected by AD. Systemic corticosteroids are medications, usually taken orally or injected, that affect the whole body.

Systemic corticosteroids reduce the production of the chemicals that cause inflammation. In AD, the immune system responds abnormally, causing an abundance of chemicals that cause inflammation, redness, and swelling. Corticosteroids reduce the production of the chemicals that cause inflammation. Short-term use of systemic corticosteroids can help in severe exacerbations of AD, including severe itching, however they have not been shown to control symptoms or induce remission long-term.1

Side effects of systemic corticosteroids

Although systemic corticosteroids can rapidly improve symptoms of AD, experts caution that their use should be time-limited and well thought-out because of the potential side effects. A rebound flare – an increase of symptoms and severity of disease – is commonly seen when systemic corticosteroids are stopped. Systemic corticosteroids also have significant potential long-term side effects, including diabetes, high blood pressure, gastric ulcers, weight gain, osteoporosis, skin thinning (atrophy), glaucoma, growth retardation, and uncontrollable emotional outbursts.1,2

Patients who receive long-term systemic corticosteroids may require antibiotics for opportunistic infections and calcium and vitamin D supplementation. In addition, these patients may require blood pressure monitoring, regular eye exams, adrenal function tests, and testing to measure bone density (in adults) and growth (in children).1

Types of systemic corticosteroids

Cyclosporine

Cyclosporine inhibits the activation of T-cells, the white blood cells that are involved in the inflammatory response of the immune system. Cyclosporine, marketed as Sandimmune® (cyclosporine), has proven to have beneficial effects on AD lesions and itching. In most patients, a short-term therapy of cyclosporine is effective and can be repeated in those with recurrent flare-ups. Potential side effects of cyclosporine include infections, kidney toxicity, high blood pressure, tremor, headache, abnormal hair growth, increased growth of the gums in the mouth, and an increased risk of skin cancer and lymphoma.1,2

Azathioprine

Azathioprine inhibits the production of T-cells and B-cells (another type of white blood cell) and reduces the inflammatory response. Azathioprine is effective in improving the skin symptoms of AD, reducing itching and sleep loss, and decreasing the bacteria Staphylococcus, which is frequently found in large numbers on the skin of people with AD. Marketed as Imuran® (azathioprine), azathioprine may cause serious side effects, including gastrointestinal disturbances (such as nausea, vomiting, and bloating), liver dysfunction, and leukopenia (a reduction in the number of white blood cells that can increase the danger of infections).1,2

Mycophenolate mofetil

Mycophenolate mofetil (MMF) is an immunosuppressant that selectively affects B-cells and T-cells, giving this medication a unique way to treat inflammatory disorders. It is marketed as CellCept® (mycophenolate mofetil). Results from clinical trials are mixed, but MMF may be helpful as an alternative therapy for severe AD that does not respond to other treatments. Side effects may include nausea, fatigue, flu-like symptoms, liver enzyme abnormalities, and infections, such as herpes zoster, herpes simplex, and Staphylococcal infection.1,2

Methotrexate

Methotrexate is an analog of folic acid that blocks the synthesis of DNA and RNA. Methotrexate is also believed to negatively affect T-cell function, and it is used to treat several inflammatory diseases and types of cancer. Methotrexate has been shown to be effective in treating the itching and reducing the severity of AD. Side effects may include nausea and other gastrointestinal symptoms (when given orally), and serious side effects, such as the suppression of bone marrow (a decrease in the production of blood cells), liver toxicity, and pulmonary fibrosis (scarring of the lungs), can occur.1,2

Dosage and scheduling of systemic corticosteroids

The formulations of systemic corticosteroids used in people with AD are most often prednisone, prednisolone, and triamcinolone acetonide. Prednisone and prednisolone come in tablet and oral solutions, and triamcinolone acetonide is an intramuscular injection. The dosage is based on the body weight of the individual patient, and dosing is tapered to decrease the risk of side effects. However, even with tapering, a flare of AD may occur when the medication is discontinued.1

Importance of good skin care for atopic dermatitis

Systemic treatments like corticosteroids do not rule out the need for topical treatments or good skin care. Good skin care is always a necessary component in treating and preventing relapses of AD and includes the frequent use of moisturizers, regular bathing, avoiding irritants, and avoiding scratching.

Emily Downward | June 2017
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