Systemic corticosteroids

Author: A/Prof Amanda Oakley Dermatologist, Hamilton, New Zealand 1997. Updated February 2016.

What are systemic corticosteroids?

Corticosteroids taken by mouth or given by intramuscular injection are often called systemic steroids. They are synthetic derivatives of the natural steroid, cortisol, produced by the adrenal glands, and have profound anti-inflammatory effects.

Systemic (cortico)steroids are also called glucocorticoids or cortisones. They include prednisone, prednisolone, methylprednisolone, beclomethasone, betamethasone, dexamethasone, hydrocortisone and triamcinolone. Fludrocortisone is predominantly a mineralocorticoid and its anti-inflammatory effects are minimal.

Prednisone and prednisolone are equivalent, and are the most commonly prescribed oral corticosteroids for inflammatory skin diseases. Oral prednisone is the most commonly prescribed systemic steroid in New Zealand.

What is prednisone used for in dermatology?

Prednisone is used for a few days (short-term) to indefinitely (long-term) in a wide variety of skin conditions including:

Systemic steroids are best avoided in patients with psoriasis.

How do systemic steroids work?

Systemic steroids work in the same way as natural cortisol. Natural cortisol has important effects in the body, including regulation of:

How do systemic steroids differ?

Systemic steroids differ in dose, mineralocorticoid potency, half-life (duration of action) and how effectively they suppress the hyphothalamic-pituitary-adrenal (HPA) axis (suppression leads to reduced production of natural cortisol).

Comparison of systemic steroids*
Equivalent dose 25 20 5 4 0.75
Mineralocorticoid potency 2+ 2+ 1+ 0-0.5+ 0
Biological half-life 8–12 8–12 24–36 24–36 36–54
Daily dose causing HPA axis suppression (mg) 25–30 20–30 7.5 7.5 1–1.5

* Comparison of systemic corticosteroids – Vancouver Coastal Health Formulary tool. Accessed 12 July 2014.

What is the usual dose of prednisone?

Generally, a higher dose of prednisone, such as 40–60 mg daily, is prescribed at first, to gain control of the skin condition. In 2–4 weeks, the dose is reduced.

Prednisone is best taken as a single dose in the morning, which is thought to reduce steroid-induced suppression of the pituitary-adrenal axis compared to evening dosing.

The maintenance dose should be kept as low as possible to minimise adverse effects.

Steroid dose is commonly characterised as:

Treatment for less than one month is considered short-term treatment. Corticosteroids for a few days or weeks are relatively safe when prescribed for acute dermatitis. Treatment continuing for more than 3 months is regarded as long term, and results in the majority of undesirable side effects.

What are the side effects and risks of short-term systemic steroids?

Side effects are rarely serious if systemic steroids have been prescribed for one month or less. The following problems may arise, particularly when higher doses are taken:

Rare and potentially serious side effects of a short course of corticosteroids include: severe infection, mania, psychosis, delirium, depression with suicidal intent, heart failure, peptic ulceration, diabetes and avascular necrosis of the hip. The risk increases with increasing dose.

What are the side effects and risks of long-term systemic steroids?

Nearly everyone on systemic steroids for more than a month suffers from some adverse effects, depending on daily dose and how long they have been on systemic steroids. The main concerns are infections, hypertension, diabetes, osteoporosis, avascular necrosis, myopathy, cataracts, and glaucoma. The list that follows is incomplete.

Cutaneous adverse effects

Cutaneous adverse effects from long-term systemic steroids may include:

Effects on body fat

Effects on the eye

Vascular disease

The effects of systemic steroids on atherosclerotic vascular disease may be due to complex metabolic changes, including:

Gastrointestinal tract

Reproductive system

Musculoskeletal system

Osteoporosis is particularly common in smokers, postmenopausal women, the elderly, underweight or immobile, and patients with diabetes or lung problems. Osteoporosis may result in fractures of the spine, ribs or hip joint with minimal trauma. These occur after the first year in 10–20% of patients treated with more than 7.5 mg prednisone daily. It is estimated that up to 50% of patients on long-term prednisone will develop bone fractures. Vertebral fractures are more common in patients on steroids, even in those with normal bone density.

Nervous system

Metabolic effects

Immune response

Live vaccines such as polio or MMR (measles, mumps, rubella) should not be given to patients taking ≥ 20 mg prednisone daily. It is safe and advisable to have other routine immunisations, such as annual influenza vaccination.

Risks during intercurrent illness or surgery

Significant intercurrent illness, trauma, or surgical procedure requires a temporary increase in corticosteroid dose, or if already stopped, a temporary re-introduction of corticosteroid treatment for up to twelve months after the steroids are stopped.

Patients who have taken ≥10 mg prednisone daily within 3 months of surgery requiring a general anaesthetic are advised to tell their anaesthetist so that intraoperative intravenous hydrocortisone can be added.

Effects of reducing the dose of systemic steroids

No tapering is necessary if a course of prednisone has been for less than one to two weeks. Steroids should be withdrawn slowly after longer courses, to avoid acute adrenal insufficiency, particularly if the medication has been taken for several months or longer.

Side effects from reducing prednisone may include:

Hypopituitary-pituitary-adrenal (HPA) axis suppression can persist for months or years after steroids are stopped.

Monitoring during steroid treatment

Regular monitoring during treatment with systemic steroids may include:

Patients on prednisone should be advised to avoid non-steroidal anti-inflammatory drugs and licorice.

Prevention of osteoporosis

Bone density scans should be considered for patients that have taken or are expected to take 7.5 mg or more of prednisone each day for three months or longer. Baseline fracture risk can be estimated from T-scores.

Current recommendations are:

Calcium, vitamin D and oestrogen are no longer recommended for prophylaxis of osteoporosis, as adverse events outweigh benefit.

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