Few drugs create quite so much alarm as corticosteroids. To some extent, this alarm is justified — if
over-used, they have dangerous side effects. But rejecting them entirely is a great mistake, because
they are safe at the right dose, and immensely useful for a variety of allergic symptoms. With the
information given here, you can use steroids as safely and effectively as possible.
Although their proper name is corticosteroids, these drugs are commonly — and rather inaccurately —
called steroids. This name adds to their doubtful reputation by confusing them with the notorious
anabolic steroids (see box on p. 142). However, the term ’steroids’ is used for corticosteroids in this
book, simply because that is the name most people recognise.
Steroids do not deal with the allergic reaction itself, unlike antihistamines (see p. 138) or
cromoglycate (see p. 148). Instead, they tackle the consequences of the allergic reaction,
inflammation.
What exactly is inflammation? The visible features of this phenomenon – for example, if it occurs in
the skin, around a scratch or cut – are redness and slight swelling. There is also soreness, and some
warmth. All these effects are produced by an influx of immune cells, intent on protecting the broken
skin from infection. These immune cells generate messenger chemicals (see box on p. 10) which boost the
inflammation, as well as attracting yet more immune cells to the area. When inflammation affects
delicate membranes, as when you suffer a sore throat for example, there can be a great deal more
swelling and discomfort.
The inflammation that follows allergic reactions is very similar to that provoked by infection,
although the balance of immune cells and messenger chemicals is slightly different. Eosinophils (see p.
19) play a particularly important role in sustaining the inflammation produced by allergies.
This influx of eosinophils and other immune cells, which lights the fires of inflammation, occurs some
hours after the allergic response itself. It is known as the Late Phase Reaction (see p. 13). Steroids
work well for allergies because they curtail the Late Phase Reaction and have a calming effect on
various immune cells, especially the eosinophils.
Steroid phobia
So many patients have a profound objection to taking steroids that doctors call it, half-jokingly,
’steroid phobia’. One of the hazards of giving information about potential side effects – as in this
book – is that it may encourage ’steroid phobia’. That would be a tragedy, because steroids really are
useful drugs that can do you a lot of good and very little harm, if used correctly. The risks are very
small when the steroids are used at low to medium doses, and targeted directly onto the inflammation.
Even with high doses, the serious side effects can generally be avoided. Please don’t use the
information here to scare yourself – instead, use it to protect yourself while getting the most from
steroid treatment.
A few effects on other body processes remain, even with the new steroids:
• Raised blood pressure – this can occur even with short-term use of steroids.
• Children may stop growing, or grow more slowly. Usually they make up for this later.
• Quite commonly, there is increased hunger (though you don’t actually need more food, and will
put on weight if you eat more than usual). Insomnia and an agitated, edgy feeling during the day may
occur. These are minor side effects, and no cause for concern.
• Side effects in the eye can occur: there is an increased risk of glaucoma and, with prolonged
use, cataracts.
• Long-term use can also result in loss of minerals from the bones, leading to thinning and
fragility (osteoporosis).
• Psychological changes may occur. Some people experi- ece euphoria or greatly increased energy
levels – with the opposite effects occurring when the course of steroids ends. At worst, steroids can
trigger paranoia or severe depression and suicidal feelings. (These effects are more likely to occur in
those with a history of mental illness. If you are concerned about this aspect, discuss the possible
risks with your doctor before taking steroid tablets.)
• Epileptics may suffer more frequent or more severe seizures.
• Very rarely, stomach ulcers develop, or other side effects in the digestive system.
• The skin may become thin, and the small blood vessels beneath it more fragile, leading to easy
bruising and stretch marks (striae). This is also a potential problem with steroid creams (see p. 146).
Elderly patients are much more susceptible to this side effect.
• Some diabetics need more insulin. in addition, anyone with the potential to develop diabetes is
more likely to do so, but only if taking steroid tablets long term. The diabetes usually goes when the
steroids are stopped.
• A few men suffer impotence, but only with long-term use of tablets. This can be treated, so see
your doctor. Women may have irregular periods.
• Damage to the hip bones may rarely occur, usually with excessive doses of steroid tablets. This
is called avascular necrosis and may require hip replacement.
In addition to these effects on other body processes, there are also some side effects that arise from
the steroids’ suppression of the inflammation. These can occur even with short courses. Again, however,
these problems can almost always be prevented, or treated, or reversed if detected at an early stage.
• Skin wounds may be slow to heal, and are more likely to become infected because of reduced
immunity. This is not a serious problem – just keep all cuts as clean as possible.
• Infections by viruses and fungi (e.g. Candida – see box on p. 83), may occur more readily.
• Some infections may be masked initially because fever is suppressed by the steroids.
• Chickenpox and measles can be far more serious – even fatal – if steroid tablets are being
taken, or have been taken for more than three weeks within the last three months. This is something to
be very careful about (see item 15 on p. 143).
• Prolonged use can increase the risk of chest infections.
• Vaccination with live vaccines can cause problems.
• Older people who once suffered from tuberculosis (TB) may find it comes back.
• Steroids can lead to pregnancy if using an IUD, because IUDs work by inducing mild inflammation
in the womb.
The most insidious effect of steroids – and remember again that this is only a hazard of prolonged
high-dose treatment – is adrenal suppression. When steroid tablets are taken for more than three weeks,
the adrenal glands’ own ability to produce cortisol (see p. 141) starts to be slightly suppressed. The
longer the course of steroids, the greater the effect. Stopping the steroids abruptly leaves the body
without enough cortisol to protect itself, which, in the very worst cases, can lead to collapse. Less
obviously, there may be greater vulnerability to the effects of accidents, serious illnesses, surgery
or childbirth – demanding events that would normally stimulate a rise in cortisol production to help
the body cope with the stress.
If you take a short course of steroid tablets during this period, there is more risk of side effects
than normal. Adrenal suppression can last for 6-12 months after steroid treatment ends. It may be two
years before the body can cope with surgery unaided and you will need low doses of steroids to get you
through stress of this kind.
Will I look like a weight-lifter?
Absolutely not. The steroids taken by unscrupulous athletes to pump up their muscles artificially are
anabolic steroids. They are entirely different from the corticosteroids used to treat allergies.
Mimicking nature
All corticosteroids are chemically very similar to a substance known as cortisol that is produced
naturally by the body. Cortisol – which is a hormone made in the adrenal glands, located near the
kidneys – has a great number of different effects, apart from damping down inflammation. It regulates
the action of the kidneys, moves proteins out of the muscles and bones, and alters the pattern of fat
distribution.
Like other hormones and chemical messengers that the body produces, cortisol achieves its effects by
binding to receptors on target cells (e.g. immune cells, muscle cells and the cells that make up the
kidneys). These receptors vary a little, which gives researchers scope for making a synthetic version
of the hormone, cunningly modified so that it binds well to one kind of receptor (the one on the immune
cells, for example) but not so well to another (the one on the kidneys).
Hydrocortisone, the original steroid drug, is identical to cortisol, but the newer steroids have been
modified chemically to have the maximum effect on inflammation and minimal effects on other body
processes. While hydrocortisone can only be used for allergies at very low doses (as in
non-prescription hydrocortisone cream), the modified steroids can be used at higher doses.
The side effects of steroid drugs are of two basic kinds:
• those due to suppression of inflammation (the desired effect of the drugs) because this
partially reduces immunity to disease
• those due to the effects of steroids on other body processes – undesirable effects which have,
as far as possible, been designed out of the modern drugs.
These different side effects are discussed in more detail on p. 142. First, it is important to look at
the crucial difference between taking steroids in tablet form and applying them directly to the
affected area. Much unnecessary anxiety can be avoided by understanding this difference.
Targeting steroids
The risks of steroids fall dramatically if, instead of taking them in tablet form, you put them exactly
where they are needed: that means drops for the nose or eyes, inhalers to get the drug into the
airways, or creams and ointments to target the skin.
The medical term for this is topical application, and it is infinitely preferable to taking steroid
tablets. When a drug is swallowed, it does its job by being absorbed through the stomach lining into
the bloodstream, and then being carried around the body in the blood. This is called systemic treatment
because it reaches the whole body-system via the blood.
The areas that need the drug – the itchy skin or inflamed airways – get their dose, but so does every
other part of the body. In order to get a useful amount to the afflicted parts, a fairly large total
dose has to be taken which inevitably affects the rest of the body, making the drug far more hazardous.
When a drug is targeted precisely, in sprays, drops, creams or inhalers, the dose used can be very much
smaller. Some of the drug does get into the bloodstream, by penetrating the skin or the membranes of
the nose or airways, and entering the tiny blood vessels that lie just below. But the amount reaching
the bloodstream is usually minuscule compared with the amount in the blood when you take steroid
tablets. Systemic side effects –those due to the drug going round in the blood (see below) – are
usually avoided, although there may be some local side effects, where the drug is applied.
Only with very powerful doses – as in the steroid inhalers used for severe asthma, or high-potency
creams for eczema – do topical steroids reach the bloodstream in sufficient amounts to cause systemic
side effects. You have to be on these treatments for a long time, or be overdoing the dose (a possible
hazard with creams for eczema), to run the risk of systemic side effects.
Steroid tablets
Short courses of steroid tablets – which means three weeks or less – are pretty safe. They are usually
sufficient to get the inflammation under control, and can be taken three or four times a year without
creating any problems.
Even if you have no choice but to take steroid tablets on a long-term basis, remember that the serious
side effects can usually be avoided, or reversed if caught early (see p. 143).
Side effects
Apart from changes that may (rarely) occur in the stomach lining, the side effects of steroid tablets
are all systemic side effects.
In the early days of steroid use, a set of side effects that resemble a disease known as Cushing’s
Syndrome were frequently seen. The side effects included deposits of fat on the shoulders and abdomen,
and around the face, producing a ,moon face’, water retention resulting in puffiness, weakening of the
bones, easy bruising, acne and muscle wasting. All these changes are due to the unwanted effects of
steroids on other body processes, not to any effect on inflammation.
With the new and improved steroids (see left), plus a much more watchful approach by doctors, these
severe side effects have become very rare, but they can still occur in those on high-dose steroid
tablets. As long as they are noticed in good time (see p. 143) the problem can be reversed.
Using steroid tablets safely
Those taking steroid tablets for more than three weeks, or taking a lot of short courses, can protect
themselves from serious side effects in the following ways:
1. Weigh yourself every day. Should your weight suddenly start to rise, despite eating normally,
consult your doctor: this may be a sign of water retention.
2. If you develop hip pain, swollen ankles, muscle weakness or acne tell your doctor.
3. Get your blood pressure checked regularly by the doctor.
4. Get your eyes checked regularly by an optician, who can detect any problems before there is
irreversible damage.
5. In the case of children, make sure the child’s growth is being monitored carefully by the doctor.
6. Stay as active as possible, with plenty of vigorous exercise, to protect against osteoporosis. Avoid
getting too thin, as this is also a risk factor for osteoporosis. Reduce your salt intake and don’t
drink too much alcohol. Ask your doctor to order a bone-density measurement periodically. Following the
menopause, women on steroid tablets should consider taking hormone replacement therapy (HRT) as this
protects against osteoporosis.
7. Persistent unexplained back pain must be reported to your doctor: this can be a sign of
osteoporosis. If you fracture your wrist in a fall (a Colles’ fracture) make sure your doctor knows
about this, and prescribes urgent drug treatment for osteoporosis.
8. See your doctor if you are over-tired, thirsty, or need to pass urine much more frequently – these
can sometimes be signs of diabetes.
9. Take your tablets after food to protect the stomach. See your doctor if you have persistent
indigestion: coated forms of the tablets may help.
10. If you ever produce black, tarry stools, call your doctor immediately. This is generally a sign of
bleeding from the digestive tract.
11. With your doctor’s permission, take all your daily steroids as a single dose in the morning. The
long gap between one dose and the next stimulates the body to maintain its own steroid-making abilities
and so reduces the risk of adrenal suppression. It can also protect against growth problems in
children. Even greater protection comes from taking steroids on alternate days – one day on, one day
off – although not everyone can keep their symptoms under control with this regime. Obviously, you must
consult your doctor before you try. Your dose may need adjusting.
12. Adrenal suppression puts you at risk during any medical procedure. Tell your doctor, dentist, and
anyone treating you in an emergency – even if you stopped taking steroids up to two years earlier. You
should also carry a Steroid Card at all times, in case you are unconscious. These cards are available
from your doctor.
13. Ask the doctor what you should do if you develop any kind of infection or suffer an accident. It is
often necessary to increase the dose of steroid tablets.
14. Tell your doctor if you have ever had tuberculosis, as this can recur.
15. If you or your child have not had measles or chickenpox, avoid contact with anyone suffering from
these diseases – or from shingles (herpes zoster) which is caused by the chickenpox virus. See your
doctor promptly if there is any contact with someone infected. Emergency treatment to combat the virus
must be started promptly.
16. When being vaccinated, remind the doctor or nurse that you are taking steroid tablets.
17. Never stop taking steroid tablets abruptly if you have been taking them for more than three weeks,
as some degree of adrenal suppression may already have begun. Your body needs time to recover its
natural level of activity, so reduce the dosage gradually. Get precise instructions from your doctor
about how to do this.
18. If you are asthmatic, at the end of any course of steroid tablets lasting more than three weeks, be
extra careful about exposure to allergens and asthma triggers. You may be more vulnerable to severe
asthma attacks for as much as a year after long-term steroid tablets are stopped, or the dosage
reduced.
Watch out for adrenal suppression
If you develop any of the following symptoms after stopping steroids,
or while reducing the dose, call your doctor as soon as possible:
• muscle weakness; muscle and joint pain
• feeling ‘under the weather’
• mental changes
• scaly or flaking skin
• breathlessness
• lack of appetite; or nausea and vomiting
• fever and weight loss
• painful itchy lumps on the skin.
Note that, very rarely, withdrawal of steroid tablets, or lowering the dose, can unmask a disease
called Churg-Strauss Syndrome (see p. 160).
Steroid nose drops and sprays
Most steroid nose drops and nasal sprays contain very low doses of the drug, and produce no significant
side effects when used for short periods of time. The safety of these preparations is such that several
are available without prescription.
Steroid drops and sprays for the nose are a very effective way of treating hayfever and perennial
allergic rhinitis. They can be used after the symptoms have begun, or in advance of encountering the
allergen.
Steroid nose drops are also useful in reducing the size of nasal polyps (see p. 30) but only if the
drops are inserted correctly. Kneel down and, bending your neck forward as much as possible, put the
crown of your head on the floor. Now put the drops in and stay in this position for several minutes
while the drops reach their target. Once the polyps have shrunk, the drops can be replaced by a steroid
spray which will keep them under control.
Always stick to the stated dose, as with any drugs – don’t use the drops or spray more often than you
should. If you have a cold or other infection in the nose, stop using steroid drops and sprays until it
is better. Following surgical operations on the nose, ask your doctor’s advice before using steroid
drops or sprays.
Side effects
Minor short-term side effects may include dryness and irritation in the nose and throat, and
disturbances of smell and taste. Nosebleeds might occur and should be reported to your doctor. When
inserting the drops, try to keep them away from the central partition of the nose (the septum), as this
is
the part most vulnerable to bleeding. If you are a long-term user of steroid nose drops, your doctor
should check the membranes in your nose regularly, to be sure that they are not becoming thinned. Eye
checks may also be advisable with long-term use, as glaucoma can occur.
Allergic reactions to the steroid are possible, and they can cause bronchospasm (contraction of the
airway muscles) though this is unusual. You should obviously stop using the drops and see your doctor
if this occurs.
With very high doses of steroids in the nose, or prolonged treatment, some systemic side effects might
occur. The main cause for concern is children’s growth (see box on p. 145) – their height should be
checked regularly.
Steroid eye drops
Steroid eye drops are sometimes given for severe inflammation of the eye during the hayfever season.
However, the eye is vulnerable to infections if treated with steroid drops, and such treatment requires
close medical supervision.
Side effects
Be extremely careful about infections – don’t rub your eyes with your fingers, for example, or dry
around your eyes with a towel unless it is absolutely clean. Follow your doctor’s instructions very
carefully, and go back immediately if your eyes become more uncomfortable, if redness increases, or if
you have any other cause for concern.
Steroid eye drops are rarely used for more than a few weeks. With prolonged use, there is a risk of two
serious side effects, glaucoma and cataract.
Using two lots of steroid
Allergy sufferers who need steroid nose drops or a nasal spray, as well as a steroid inhaler, often
worry that they are getting too much steroid overall.
In fact there is no cause for concern, unless you are taking very high doses of inhaled steroid, in
which case talk the matter over with your doctor. The amount in most nose drops and sprays is quite
small and the same is true of steroid eye drops. In all cases, relatively little gets into the
bloodstream.
If you have allergies in the nose, this may well be making your asthma worse, and using steroid nose
drops can be very helpful for the asthma symptoms (see p. 39).
Inhaled steroids and children’s growth
If an asthmatic child inhales relatively high doses of steroids for many years, his or her growth can
be stunted. However, only a small number of children need these high doses, and with low to moderate
doses most children’s growth is unaffected. They may experience a short-term slow-down in growth, but
their eventual height should be normal.
Unfortunately, there are a few children whose growth is stunted even by relatively low doses of inhaled
steroids - and it is impossible to predict which children will respond in this way. However, if it is
noticed in good time, and if the steroids can be withdrawn safely, the child’s growth rate will almost
certainly recover.
Your GP or paediatrician should be monitoring your child’s growth. You can also measure this yourself,
and go back to the doctor if you are concerned. Keep the risks in perspective - uncontrolled severe
asthma also stunts children’s growth, as well as endangering the child in far more serious ways, so
don’t stop using the steroid inhaler.
Steroid inhalers
Inhaled steroids are a key part of the modern treatment of asthma (see p. 157). As with other topical
treatments, inhaled steroids are a great deal safer than steroid tablets. However, some of the drug
does get into the bloodstream, and with high-dose inhaled steroids taken for several years, the levels
can be high enough to cause systemic side effects such as osteoporosis (see p. 142).
The dose is the crucial factor here. The packaging or information leaflet that comes with your inhaler
will tell you how much of the drug is delivered with each inhalation. To interpret the information
about side effects correctly, you need to know your total daily consumption of inhaled steroid, and
whether this corresponds to a low, medium or high dose:
• For budesonide or beclomethasone, two of the more common steroids, less than 400mcg
(micrograms) per day counts as a low dose for adults and children over the age of five. A moderate dose
is 500-800mcg per day, and more than 800mcg a day is a high dose.
• For fluticasone (Flixotide), halve these figures (i.e. more than 400mcg a day is a high dose).
• In the case of children under five, all these figures should be halved (e.g. a high dose of
beclomethasone is more than 400mcg a day).
• For other steroids, check with your pharmacist.
Anyone taking a low or moderate dose has very little to worry about as regards systemic side effects.
Only those inhaling high-dose steroids for many years need feel concerned.
If you may be at risk of systemic side effects, follow the protective measures described for steroid
tablets on p. 143. Apart from growth suppression in children (see box above) the most likely effects
are osteoporosis, adrenal suppression, and a recurrence of tuberculosis.
You can minimise the risk of systemic side effects from
steroid inhalers by swallowing as little as possible of the steroid. Always rinse out your mouth,
gargle, and spit out the water after using your inhaler. Using your steroid inhaler morning and
evening, just before brushing your teeth, will make it much easier to remember to do this.
Bear in mind that inhaling steroids regularly will help you avoid the need for steroid tablets.
Asthmatics who are worried about side effects sometimes skip doses of their inhaled steroids, then find
their asthma is much worse and that they need a course of steroid tablets. Frequent courses of tablets
increase the risk of serious side effects.
Minor local side effects of inhaled steroids include hoarseness and short-lived coughing due to direct
irritation of the throat. These are no cause for concern.
If you are regularly inhaling steroids from a nebuliser, make sure the mask fits really well (see p.
163).
Because steroids reduce the immune defences a little, one common side effect of inhaling them is a
throat infection by Candida (see upper box on p. 83). Oesophageal infections with Candida can also
happen but these are rare; the symptoms are heartburn and indigestion. Gargling with warm water after
each inhalation will help prevent Candida infections. There are also anti-fungal lozenges, if you are
still having trouble.
Keep inhaled steroids away from your lips if you suffer from cold sores (herpes infections around the
mouth). These can be made worse with steroids.
Fortunately, other infections are no more common when using inhaled steroids. This includes chest
infections.
Recent research has found other side effects in children using high doses of inhaled steroids. Cough
and thirst are common, while hoarseness and loss of voice affect quite a few. Behavioural problems also
occur, including hyperactivity, mood swings, excitability, sleep disturbances, depression, and even
hallucinations.
Steroid creams and ointments
Steroid creams and ointments are used for both atopic eczema and contact dermatitis. By delivering the
drug to the place where it is needed, they reduce the dose required to an absolute minimum and, if used
correctly, are very safe. Dr Ernst Epstein, a dermatologist at the University of California, observes
‘All too often I encounter children who are miserable with uncontrolled atopic dermatitis because of
their parents’ unjustified fears of steroid side effects. It is cruel to the child and the family to
forgo topical medication.’
It is very important to use a steroid cream of the right strength. For example, applying a 1%
hydrocortisone cream (available without prescription) to severe atopic eczema will be of no value.
Similarly, only applying a prescribed cream occasionally, or only once a day when the doctor said three
times a day, will mean that the rash never really succumbs to the treatment.
Keeping old tubes of steroid cream in the bathroom cabinet, and using these rather than the newly
prescribed cream, is another frequent mistake. If the earlier prescription was for a weaker steroid
cream, that is not quite up to the job, you won’t get the symptoms under control.
Inadequate treatment means that the rash goes on longer, so you probably apply more steroid in the long
run – which exposes you to a greater risk of local side effects. It is far better to use a moderately
strong steroid cream for a short period of time and get the inflammation fully under control.
Remember that steroid creams are absorbed far more effectively immediately after a bath or shower, so
this is a good time to apply them (see p. 48).
Don’t stop using steroid creams too soon. The skin looks healthy and happy long before it is completely
healed underneath. You must continue until the ‘hidden healing’ has occurred. As a rough guide, the
point when the skin looks good is just the halfway point: so the steroid creams should be continued for
the same length of time again. If it took three weeks to get to the point where the skin looks fine,
then you should go on applying the steroid creams for another three weeks after that.
Generally speaking, it is a good idea to phase out steroid creams slowly, especially after using them
for a long period of time. Stopping abruptly may cause the rash to flare up again –this is called a
rebound effect.
Once you have atopic eczema under good control, you will still need some steroid cream at home for
dealing with relapses. As soon as you notice any rough, itchy skin, apply the cream twice daily for
three days, then once daily for another three days. This should be enough to curb the outbreak of
eczema before it really gets going.
Side effects
To assess the risk of side effects from your steroid cream or oirtment, you need to know how strong it
is. Four grades are recognised: mild (corresponding to non-prescription hydrocortisone cream),
moderately potent, potent and very potent. Ask your doctor or pharmacist which grade corresponds to
your cream, so that you can make sense of the information given below.
Unfortunately, if steroid creams are not used correctly, there are some quite serious local side
effects. Any steroid cream that is strong enough to work is also strong enough to produce side effects
if over-used, so this is a delicate balancing act. The main local side effects are thinning of the skin
and striae (stretch marks). Teenagers and pregnant women are particularly susceptible to stretch marks
if using steroid creams.
It is important to take care because these side effects can be irreversible. The stretch marks, for
example, may fade in time but never entirely disappear. Sustained over-use of steroid creams can
produce permanent thinning of the skin. Thinning of the ski on the face may produce redness, with small
blood vessels shoving through. The fingertips may develop painful cracks.
Note that these side effects can come on very gradually.. Some may be mistaken for symptoms of the
disease itself.
Other local side effects may include an outbreak of spots that look rather like acne. Increased
hairiness or change in skin colour are also possible. Fortunately these effects are reversible.
To avoid side effects, follow the instructions for using steroid creams carefully, and don’t apply too
much or too often. If you have not been given clear instructions by your doctor on the quantity to use,
go back and ask for more information. Ideally, you should actually be shown the correct amount of the
cream to use each time. Remember to wash your fingers after applying steroid creams
If potent or very potent steroid creams are slapped on W& abandon, enough is absorbed into the
bloodstream to produce systemic side effects, comparable to those that can occur with steroid tablets
(see p. 142).
With very potent steroid creams, used for a long period of time, there is some risk of slight systemic
side effects even though the instructions for use are carefully followed. Young children more
susceptible. Bear in mind that covering the skin with cages after applying the cream increases the
amount absorbed into the bloodstream. The degree of adrenal suppression caused by using the cream (see
p. 142) is probably going to remain unnoticed in everyday life, but a major illness, accident,
childbirth or a surgical operation might reveal the problem – so tell medical what you have been using.
Different areas of the body respond differently to steroids creams. The skin of the face, and within
skin folds.
sensitive and generally requires a lower-strength cream, while the palms of the hands and the soles of
the feet require a higher strength. The genitals and the area around the anus are particularly
sensitive, and can become permanently damaged (and then a source of intense discomfort) by strong
steroid creams: some dermatologists recommend using nothing stronger than 1 % hydrocortisone.
Make sure you see your doctor regularly when using steroid creams continuously, especially if:
• you are using very potent steroid cream
• you are applying potent or moderately potent steroid cream over more than 20% of your body for
more than a month
• you are applying potent steroid cream to a baby or young child.
The vehicle – the cream or ointment base in which the steroid is carried – is important because
sensitivity reactions can occur to certain of its ingredients (see p. 45). Eczema sufferers can even
become sensitised to the steroid itself, and this problem is difficult to diagnose because patch tests
with steroids often give false negatives (see box on p. 91). If you are not getting better, ask the
doctor if this could be the explanation. (If a rash gets worse and starts to spread when you begin
using steroid creams, go back and see the doctor very promptly – you may have an infection called
tinea, or ringworm, which flourishes all the more when steroid creams are applied.)
Tacrolimus and pimecrolimus
These are new treatments for atopic eczema. They are not steroids, but are covered here because they
are an alternative to steroid creams and ointments, and if you are comparing the two treatments it may
help to have the information on them side-by-side.
Tacrolimus ointment (brand name Protopic) is for the treatment of moderate to severe atopic eczema, and
pimecrolimus ointment (brand name Elidel) is for milder atopic eczema, especially in children.
These drugs are immunomodulatory rather than immune-suppressive – they adjust the balance of immune
reactions in the
skin. Unlike with steroid creams, there is no risk of thinning the skin, so they can be used on
delicate areas like the face and eyelids.
These treatments are generally used for patients who are not getting better with moisturisers and
steroid creams. Because they cost so much more (about ten times as much as topical steroid treatment),
and since much of the fear of steroid creams is unfounded, doctors are reluctant to prescribe
tacrolimus ointment ,on demand’. With time, the cost of these treatments may fall.
One important advantage of tacrolimus and pimecrolimus ointments is that they may have good effects
that persist after you have stopped using them. And the benefits are cumulative: in one trial where
babies with atopic eczema were treated with pimecrolimus ointment on an as-needed basis, most had fewer
and fewer flare-ups as the months went by. This was not true of babies being treated with steroid
cream.
As with topical steroids, the effect of tacrolimus and pimecrolimus on infections such as
Staphylococcus aureus is surprisingly beneficial: the enormous improvement in the surface structure of
the skin keeps bacteria out. But heavily infected skin should be thoroughly treated with antibiotics
before you start. While using the ointment, watch out for any signs of infection, especially herpes
(see p. 44), and see your doctor immediately.
Minimise your exposure to UV light – in sunlight and sunlamps – because of the tendency of UV to
provoke skin cancers. With the dampening effect that tacrolimus has on the immune system, the risk of
skin cancers may be a little higher.
Don’t apply anything else to the skin (not even moisturisers) within two hours of putting on the
tacrolimus ointment – they dilute the treatment too much. And don’t apply tacrolimus ointment
underneath bandages or other dressings.
Side effects
A few patients find that, while using tacrolimus ointment, skin in areas not being treated actually
gets worse. Talk to your doctor if this happens. Other possible side effects include stinging and
burning when applied, or redness. These are nothing to worry about, and usually lessen with time.
Some common brand names
Common brand names of steroids include:
nose drops – Betnesol, Vista-Methasone
nasal sprays – Beclometasone, Beconase, Flixonase, Nasacort, Nasonex, Rhinocort Aqua, Syntaris eye
drops – Betnesol, Cloburate, Maxidex, Predsol, Vista-Methasone
inhalers – Aerobec, Becloforte, Beclometasone, Becotide, Flixotide, Pulmicort
tablets – Betnesol, Cortisyl, Dexamethasone, Medrone, Prednesol, Prednisolone,
creams – Adcortyl, Betnovate, Dermovate, Fucibet, Synalar
