Using steroids correctly and avoiding side effects

Steroid ointments, creams and lotions can be very effective in treating skin rashes. This means that they're especially useful in the treatment of inflammatory skin conditions such as psoriasis or any type of eczema. But for many other skin conditions they are ineffective or even harmful. Acne, rosacea and infectious diseases such as a fungal skin infection can even be made worse by steroid medications. So it's important to have an exact diagnosis before using steroids.

The possible side effects of topical treatment with steroids are inflammations of the hair follicles, mild pigmentation disorders on the skin (white spots) and stretch marks. Many people are especially concerned about their skin getting thinner. If that happens, small, widened blood vessels under the skin that look like spiderwebs become visible (this is known as spider veins or teleangiectasia). But if topical steroids are used properly, the risk of these and other side effects is very small. And if the skin starts to change and the treatment is stopped, the skin can then recover.

In order to avoid side effects, the strength of the steroid medication has to be suitable for the thickness and sensitivity of the skin area to be treated.

Not all steroids are the same: There are more than 30 different glucocorticoid drugs of varying strength (potency). They are divided into four groups:

• Low-potency topical steroids, e.g. hydrocortisone and prednisolone
• Medium-potency topical steroids like prednicarbate, methylprednisolone aceponate
• High-potency topical steroids such as betamethasone valerate and mometasone furoate
• Ultra-high-potency topical steroids, such as clobetasol propionate

Steroids are more potent where the skin is thin and sensitive, particularly on

• the face,
• the inner sides of joints, such as the back of the knee, the insides of the elbows and upper arms, and the armpits, as well as
• the eyelids and genitals.

Low-potency or medium-potency medication is usually enough for treating the face and the skin on the inner sides of the joints. Eyelids and genitals should only be treated with low-potency medication. Higher-potency medication is often needed to treat the scalp and the hands and feet. The skin in these areas is relatively thick, so only small amounts of the medicine can reach the deeper layers of skin. But the risk of the skin thinning on these parts of the body is very low, even if high-potency medication is applied.

Besides the potency of the medication and the thickness of the skin, the effects of a steroid medication depend on the following factors:

• The dose
• The type of product: Steroid ointments are a little stronger than steroid creams or lotions. This is because steroids are more easily absorbed by the skin when applied as an ointment.
• How it is applied: Topical steroids have a stronger effect when applied to wet skin – for instance after taking a bath – than when applied to dry skin. If you also cover the area of skin with a bandage or a wet wrap, it will absorb much more of the drug. It is especially important to keep this in mind with young children if the treated area of their skin is covered by a diaper (nappy).

Many people who use steroid medications on their skin tend to apply either too much or too little, usually because they’re not sure how to apply them correctly or because they’re afraid of the side effects. You can use the fingertip unit (FTU) to get an idea of how much to use: One FTU is the amount of ointment that fits on the last section of an adult's finger (see illustration). This is about 0.5 grams. One half of a FTU is enough to apply to an area of skin the size of the palm of one hand plus the insides of the fingers.

 Depending on the area of skin, the following amounts (in FTUs) are recommended:

Steroids are injected for the treatment of conditions like carpal tunnel syndrome, bursitis, frozen shoulder, and inflammatory joint diseases like rheumatoid arthritis. The steroids are injected directly into the affected joints or muscles. This can cause pain and swelling at the site of injection. Repeated injections can also cause the skin at the site of injection to become permanently lighter in color. Muscles and ligaments may be weaker for a few days after the treatment.

Serious complications are very rare. They include joint infections, tendon ruptures (after injections into the shoulder joint) and nerve damage (such as after injections into the carpal tunnel).

In order to prevent side effects as much as possible, doctors recommend waiting four to twelve weeks between injections. There is no generally accepted upper limit for the overall number of steroid injections. That will depend on various factors, including what condition is being treated.

Steroid sprays are available as inhalers (to be breathed in deeply) or as nasal sprays. Inhalers are mostly used to treat respiratory diseases like asthma or chronic obstructive pulmonary disease ( COPD). If steroids are inhaled, they can cause coughing or hoarseness. An oral (mouth) fungal infection may develop as well, especially in people with a weakened immune system. To prevent that from happening, doctors recommend thoroughly rinsing your mouth and throat after inhaling. In rare cases, steroid sprays can also cause an allergic reaction with redness and itching in the mouth and on the face. If this happens, you can try out a different medication.

Long-term steroid treatment (e.g. for asthma) can temporarily cause a minimal growth delay in children. Adults have a slightly higher risk of developing cataracts over time. The risk depends on various factors, such as the dosage of the medication and how long it is used for. But using steroid inhalers rarely leads to long-term side effects: If the right drug is used correctly, long-term treatment usually has no negative effects.

Nasal steroid sprays are commonly used for allergic rhinitis or chronic sinusitis, for instance. They reduce swelling in the membranes lining the nose and the sinuses. In allergic rhinitis, they reduce symptoms such as a runny nose or sneezing. In sinusitis, the spray helps to make it easier to breathe through the nose. Side effects may include dry membranes lining the nose, as well as nosebleeds. Applying a non-steroid ointment to the lining of the nose can relieve the symptoms caused by dryness.

Oral steroids (tablets) can be used to treat flare-ups in a number of different chronic inflammatory conditions, especially if other treatments aren’t effective enough. These conditions include multiple sclerosis, rheumatoid arthritis, and inflammatory bowel diseases like Crohn's disease and ulcerative colitis. Oral steroids are also used to treat allergic reactions.

Steroids may have stronger side effects when taken as tablets rather than being applied topically (to the skin) or to a certain area. This is because the steroids in tablets enter the bloodstream and so they have an effect throughout the entire body. But here, too, the risk of side effects depends on the specific drug, the dose and how long it is used for. Serious side effects are believed to be rare when steroids are used for only a few days or up to two or three weeks at the most. But it’s still important to not continue treatment any longer than necessary and to use the lowest dose that is effective. Long-term or repeated use increases the risk of side effects.

It’s also important not to stop taking steroid tablets abruptly after long-term use. To help you to gradually reduce ("taper") the dose towards the end of the treatment, your doctor will put together a schedule for you to follow.

Possible side effects in long-term treatment are:

• Food cravings, often associated with weight gain
• Sleep disorders
• High blood pressure
• High blood sugar levels
• High cholesterol levels
• Osteoporosis
• Skin thinning
• Acne
• Higher risk of infections
• Higher risk of thrombosis
• Cataracts or glaucoma
• Change in mood, like mild irritability and depression
• Stunted growth in children
• Stomach ulcers
• Cushing's disease: A disease that causes symptoms such as fat deposits in the face and stretch marks.

Not every oral steroid causes all of these side effects. The probability of a side effect occurring also depends on whether you have any other medical conditions. Some side effects are temporary and only last as long as you take the medication, while others may last longer.

It is possible to lower the risk of certain side effects. For instance, you can try to prevent stomach ulcers by taking medication to protect your stomach, like proton pump inhibitors. Regular check-ups (e.g. to measure blood pressure, blood sugar or bone density) can help doctors to detect possible complications early. In order to avoid infections, it’s a good idea to stay away from people who are ill. Before getting a vaccination, you should tell your doctor if you take steroid tablets regularly.

Steroid tablets can increase or decrease the effects of other medication, so it’s important to also tell your doctor which other medications you take before starting treatment with steroid tablets.

Steroid tablets are usually taken in the morning with breakfast, unless otherwise prescribed.