Posts Tagged ‘surgical operations’

Allergens and irritants at work
Some workplaces have very high concentrations of allergens in the air, especially if proper safety procedures are not being followed. Occupational allergies can begin with symptoms in the nose, such as sneezing, blockage or constant streaming (allergic rhinitis). You may also suffer with itchy or watery eyes (conjunctivitis), a cough, sweating and a feverish feeling. Alternatively, direct contact with the allergen can produce a skin rash (dermatitis) or itchiness and swelling (contact urticaria/nettle rash and angioedema).
If you work somewhere with an allergy risk (see pp. 133-4), be vigilant for such symptoms and see your doctor immediately. These symptoms can be the forerunners of occupational asthma, which is a serious and potentially irreversible problem. Some allergens, such as latex, can even produce anaphylactic shock (a life-threatening allergic collapse).
Skin-prick tests (see p. 91) can show if you have an allergy to a substance encountered at work.
Acting promptly gives you the best possible chance of recovery and is vital if you have occupational asthma. Only if exposure to the allergen stops promptly do you have a good chance of shaking off the asthma. See your doctor as soon as possible and ask for a referral to a chest specialist, so that a definite diagnosis can be made. This is essential if you are going to make a claim for compensation.
Far too many people with occupational asthma are just sent off with an inhaler when they first see their doctor. By delaying the moment when work is identified as the source of the problem, and the exposure to the allergen is stopped, drug treatment can turn occupational asthma into a disabling lifelong problem. Although drugs can be helpful in speeding your recovery once exposure to the allergen
Latex allergy
Sensitisation to latex usually occurs at work (see pp. 133-4), or as a result of having many surgical operations. But latex allergy sometimes occurs in allergy-prone people even though they don’t work in a high-risk job and haven’t had many operations. Some doctors think that if a child with severe allergies needs surgery, this should be done in latex-free conditions, even though the child has no allergy to latex, because of the risk that the operation will sensitise.
Latex can cause either contact dermatitis (see p. 55) or a Type I allergy, whose symptoms can include urticaria, asthma and anaphylaxis. Latex allergy often goes undiagnosed. Once sensitised, you may react to balloons, elastic bands, condoms and household gloves. Latex in the air,
due to powdered latex gloves being used, can be a hazard for someone who is highly sensitive, as can latex traces in food (see box on p. 175). Medical treatment may be problematic (see p. 98 and box on p. 249). Cross-reactions to certain foods can occur (see p. 15 and p. 51).
For those avoiding latex, there are non-latex gloves (see p. 57), and non-latex condoms. Immunotherapy (see pp. 164-9) may be useful in severe cases: it can reduce sensitivity and eliminate cross-reactions to foods.
Other hazards
This article (pp. 132-5) deals mainly with allergens at work, that is, substances which provoke classical allergies (Type I reactions). In addition, there are skin irritants and antigens in workplaces which can provoke contact dermatitis (see p. 56) or contact urticaria (see p.50).
Some of the most dangerous workplace substances are those that bring on asthma but are not allergens. These are usually called low-molecular-weight asthmagens. The most notorious of these are platinum salts, isocyanates (used in cement, in the manufacture of foam, plastics and varnishes, and for spray-painting cars, aeroplanes and boats), colophony (used as a solder in electronics), glutaraldehyde (used in hospitals for sterilisation procedures), and persulphate (used in hairdressing). Powerful respiratory equipment, supplying air from outside the area (see p. 135) is needed if you work with some of these substances, e.g. isocyanates for spray-painting cars.
has ended, they should not be seen as a way of allowing you to go on working with the offending allergen or asthmagen.
If it seems plausible that your allergies or your asthma are related to your work, your doctor should be able to give you a sickness certificate, so that you can have some time away from the workplace, to see if you recover. The medical service at your workplace may be better at diagnosing occupational asthma than your own doctor, but be cautious. In some workplaces they do operate as they should and offer genuinely confidential treatment. But there have also been cases of information being passed to the management, and workers with the early signs of occupational allergies and/or asthma being dismissed on a pretext, or made redundant, to avoid a possible compensation claim. Most occupational health services claim to be independent, but they actually have to earn the trust of the workforce. Before you make any move, ask your colleagues for their views, especially those who have worked there for many years.
Choosing a job
If you have any tendency to allergies, or come from an allergy-prone family, you should be very choosy about where you work. Try to avoid workplaces where there is heavy exposure to allergens, especially airborne allergens which can provoke asthma:
• Bakeries and flour mills, where the allergens concerned may be wheat proteins in the flour, or enzymes added to the flour mix. These allergies can take years to begin.
• Other food-processing works, particularly those dealing with tea, soyabeans, other beans (e.g. gram flour), shellfish and fish (especially if automated gutting machines are used without adequate ventilation). Food preparation and sandwich-making can cause contact urticaria, if there is prolonged contact with a particular foodstuff (e.g. tomatoes).
• Farms, docks and cotton mills – or any other workplace generating dust from plant products. On farms, it is the dust from grain and hay that is often responsible, although mould spores (see p. 121) can also be the culprit. Allergies to mites (found in hay, grain and flour) sometimes occur and eczema is the most common symptom – often called simply ‘grain itch’.
• Saw mills and joineries, because of the wood dust, especially that from hardwoods and from red cedar (Thuja plicata).
• Paper recycling plants, if there is a lot of paper dust in the air.
• Detergent and pharmaceutical factories handling enzymes – these are added to ‘biological’ washing powders and are potential allergens. The risks are less these days, as the enzymes are in granule form rather than powder.
• Factories processing natural products such as psyllium or ispaghula, which are used as laxatives. Anyone who has been sensitised should avoid taking medicines containing the offending substance in the future, because these can sometimes provoke a dangerous anaphylactic reaction.
• Hospitals, clinics and dental surgeries, mainly due to latex rubber, used in gloves and equipment. Although nursing staff and surgeons are most susceptible, other staff including hospital administrative workers can occasionally be affected. Fears about the spread of the HIV virus has led to a huge increase in the use of latex gloves in medicine and dentistry, and a consequent epidemic of latex allergy. The main problem is with powdered latex gloves, which release 15,000 times as much allergen into the air as unpowdered gloves. Unpowdered, low-allergen gloves greatly reduce the risk of latex allergy developing, and non-latex gloves are even better. There are moves to ban the import of powdered latex gloves into Britain. They are already being phased out in hospitals and other medical facilities, but progress is slow in some areas.
• Other workplaces where powdered latex gloves are used, including
Making the workplace safe for everyone
Note that these choices about employment are for the individual employees to make for their own protection - an employer cannot refuse to take anyone on because they have allergies or come from an atopic (allergy-prone) family.
The reasoning behind this is that the workplace should be safe for everyone, as far as possible. As many as one in three of the population may be susceptible to allergies, and it is clearly wrong to bar all such people from major industries. Current thinking, in most countries, is that the focus should be on getting allergens and asthmagens out of the air, not keeping the more vulnerable workers out of the workplace.
hairdressers, dental surgeries, pathology laboratories and police stations. Construction workers wearing rubber gloves are also at risk. Someone who has been sensitised by powdered latex gloves may then react to other items (see box on p.132). Those severely affected can have great problems in daily life and with medical treatment, so anyone with a strong tendency to allergy should strenuously avoid becoming sensitised.
• Factories making or using rubber items may also expose workers to the risk of latex allergy. Anything made by the ‘dipping method’ (e.g. balloons, condoms, elastic bands and gloves) is highly allergenic. Moulded rubber items, such as tyres, are much less of a problem. Neoprene and other synthetic rubber items are not allergenic.
• Chiropody and podiatry clinics, where there is a risk of allergic reactions to the fungus that causes athlete’s foot. It is inhaled on skin flakes from the patients’ feet.
• Laboratories and other workplaces where animals are kept. In the case of mice, rats and other rodents, the allergen is found in the animals’ urine, and becomes airborne as the urine dries. Insects and spiders (e.g, those reared for biological pest control), are also allergenic due to small airborne particles from their bodies. Those working closely with bees (either honeybees or bumblebees, now reared for pollinating glasshouse crops) are liable to be stung frequently, and this can lead to sting allergy (see pp. 60-61).
• Hairdressing salons, where many different items are used that are potentially allergenic, including latex gloves (see above), permanent-wave solutions and henna. The risks of contact dermatitis are also high (see p. 55).
• Greenhouses, where the enclosed conditions can lead to high levels of allergens from plants, moulds and insect pests. There may also be exposure to pesticide sprays or their residues, which can greatly aggravate any underlying tendency to allergies.
If you have ever suffered from atopic eczema, work situations that can bring on contact dermatitis should also be avoided (see p. 55).
Taking a risky job
If circumstances force you to take a job with an allergy risk, observe all the safety procedures that are in place, and where you have the option of turning on extractor fans, wearing protective gear, or simply opening doors and windows, always do so. If the safety procedures seem inadequate, talk to your trade union Safety Representative, or the local Health and Safety Executive which can run a check on safety procedures in your workplace. This will be presented to the employer as a routine check, so they need never know that a member of the workforce has contacted the HSE.
Whatever you do, if you are in a risky job, don’t smoke. At a salmon processing plant in Scotland, 40% of the smokers developed allergies (resulting in asthma) to the fish allergens in the spray from the fish-gutting machine. Non-smokers - who formed the overwhelming majority of the workers - were not affected at all. In United States cotton mills, smokers are affected by levels of cotton dust in the air that are legally defined as ’safe’, while nonsmokers remain unaffected.
Passive smoking at work is also an important issue. A recent US study showed that non-smokers were more likely to develop asthma if they worked alongside a smoker. Your employer has a duty to provide you with clean air. This includes ensuring that other employees do not impose their cigarette smoke on you.
Respiratory equipment
Where respiratory equipment is needed, your employer must provide this, and it must be the right equipment for the job. It should be inspected, tested, cleaned and repaired after each use, and filters should be replaced regularly. All this is your employer’s responsibility, but check that it is being done, and always look the mask over before you put it on.
Two different types of respiratory equipment are currently in use:
• Those that give you a supply of air from outside the work area, either from a compressed-air cylinder, or via an air-hose (airline) supplied with fresh air. In Britain these are called breathing apparatus.
• Those that use the surrounding air but filter it to remove allergens and asthmagens. In Britain these are called respirators. (In some countries this term describes any kind of respiratory equipment.) Ordinary respirators may pose problems for some asthmatics because they cannot breathe in strongly enough to draw sufficient air through the filter. Powered respirators can be the answer: they have a battery-powered unit to help with pulling in the air.
There are government regulations concerning the type of equipment required for each type of allergen and asthmagen. Large companies generally follow these regulations, but small businesses, such as local sawmills, joineries and car-repainting workshops, may not even know about them.
Any respiratory equipment that has a face mask must form a tight seal with your face. Facial hair will prevent this, and so will stubble, so shave carefully. Faces vary enormously in shape, and if your face mask does not fit, ask for a different type of mask or a different type of respiratory equipment. Persist until you get one that’s right for you.
Carry out a ‘fit check’ each and every time you wear the mask. For example, with respirators, you can check the fit by covering the air intake completely with your hand and breathing in sharply: if the mask fits properly, it should collapse onto your face, and remain stuck to your face for several seconds. Look at the manufacturer’s instruction booklet as there may be a specific fit check recommended for the equipment you are using.
If there is any difficulty in breathing through the respiratory equipment, the replaceable filter cartridge or the equipment itself should be replaced. You should also take action immediately if you can smell the substance being handled – but never rely on this as a danger sign, because an extremely small amount, way beyond the detection capacity of the human nose, may be very damaging indeed to your health.
Keep your mask on throughout the work period. If you find this impossible, talk to your employer or
line manager about getting a different kind of respiratory equipment – a powered device, for example, that assists the inflow of air.
No form of respiratory equipment provides complete protection against allergens and asthmagens: there is always the chance of some small amount getting through. This is why respiratory equipment should not be used by those who have already developed occupational asthma but want to stay in their job.
Those who really cannot change jobs (e.g, farmers) are sometimes able to use a powered respirator helmet, which allows them to go on working despite the allergen. But this is not an ideal solution from a purely health point of view. Farmers can also improve matters, where moulds are the source of allergens, by keeping all harvested crops dry and thoroughly ventilated.
A lasting problem
As long as you catch the problem early, and are no longer anywhere near the allergen, your symptoms should disappear completely, but remember that you may still be highly sensitive to the allergen, even years afterwards. For a year or two at least, avoid contact with it again, even in tiny amounts. If someone else in your family works at the same place, they may bring home traces of the allergen on their clothes and hair: ask them to leave their workclothes outside the house and shower on arriving home.
With occupational allergies to airborne food particles, it is possible that the affected individual will later react to the same food when eaten. Experiment very cautiously, especially if the allergen is fish or shellfish.
The allergy may persist long after the job has ended. In one case, doctors found that a woman who had developed ‘baker’s asthma’, while working briefly in a bakery when young, was still allergic to the enzyme additive in bread 20 years later. She suffered an asthma attack whenever she ate bread.

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