Synthetic Corticosteroids, Natural Corticosteroids, and Your Skin
To understand the role synthetic corticosteroid drugs have in the treatment of mild-to-severe dermatitis, including eczema and psoriasis, it is helpful to be acquainted with the natural roles steroids play in the body. Topical and systemic synthetic corticosteroids have become a primary therapeutic answer for many inflammatory conditions because of the powerful anti-inflammatory properties they share with their natural analogs. Applying synthetic steroids to address inflammation may be effective in reducing symptoms, but the broad action of both natural and synthetic steroids in many metabolic pathways is what warrants caution as to the amount, potency, duration, and how and to whom the synthetic versions should be applied.
The natural steroids with which Nature endows us are produced through interactions along the hypothalamus-pituitary-adrenal (HPA) axis. These interactions result in the adrenal glands secreting hormones that regulate a vast range of metabolic processes, including salt and water retention (mineralocorticoids—aldosterone), the stress response and inflammation (glucocorticoids—cortisol and corticosterone), and processes moderated by the sex hormones (progestagens, androgens, and estrogens). The glucocorticoids, possessing strong anti-inflammatory properties, are the models from which the synthetic corticosteroids have been developed.
Of the glucocorticoids cortisol, produced in concentrations ten times that of corticosterone, is primary. Cortisol performs critical, essential-to-life roles in carbohydrate, fat, and protein metabolism. Cortisol helps maintain body fluid balances and blood vessel integrity, regulates blood pressure, assists in maintaining normal kidney function, up-regulates expression of anti-inflammatory proteins, and down-regulates inflammatory cytokines, as well as moderating nervous system responses. Cortisol and other hormone products invoked along the HPA axis are engaged in the essential balancing acts that occur to continuously regulate everyday metabolism. And as if that were not enough, they also play crucial roles in mediating the extraordinary complexities in the proper growth of the brain and organs of a developing fetus.
A deficiency or an excess of cortisol due to injury or disease that affects the HPA axis, or through the excessive use of potent synthetic corticosteroids, or the sudden withdrawal of use, affects a broad range of processes mediated by these essential, life-sustaining substances.
While maintaining a balance between many different metabolic systems, the level of cortisol in the blood also acts on the hypothalamus-pituitary-adrenal axis to regulate the formation of additional steroids. With release of corticotropin-releasing hormone (CRH) from the hypothalamus, the pituitary gland releases adrenocorticotropic hormone (ACTH), which in turn stimulates the adrenal cortex to secrete the glucocorticoids. Cortisol levels in the blood down-regulate the secretion of ACTH in a negative feedback loop, preventing additional cortisol from being secreted.
This concept will be important when we discuss long-term use of synthetic corticosteroids because of the metabolic balance that must be achieved, either by naturally occurring levels of cortisol or by its synthetic analogs.
Corticosteroids are available in a full range of potencies from very mild to super-potent, and formulated into topical creams, ointments, gels, shampoos, solutions, and sprays for direct application on the skin. Mild formulations are available in over-the-counter creams and ointments, not requiring a prescription, whereas more potent forms do require a prescription. Asthma sufferers rely on strong to potent corticosteroid inhalants for immediate relief from acute asthma. Used in the treatment of many inflammatory diseases from multiple sclerosis to Crohn's disease, colitis, and rheumatoid arthritis systemic steroids can be taken by mouth in pill form, or are administered by injection. Psoriasis and eczema sufferers with moderate to severe symptoms commonly use potent topical corticosteroids in combination with other systemic drug regimes, such as methotrexate, acitretin, and cyclosporine.
Corticosteroids as medications are synthetic derivatives of cortisol and are potent anti-inflammatory agents. Like their natural analogs they sometimes possess dual properties similar to other adrenal hormones. Clobetasol propionate™, for instance, a very potent topical psoriasis medication, mimics to a high degree the anti-inflammatory activity of cortisol but also possesses some of the activity of the mineralocorticoid aldosterone that regulates water retention. The synthetics can quite effectively replace or supplement the natural substances affecting the same metabolic pathways.
The risk of side effects increases with the potency of the medication used. Those using these treatments are advised to strictly follow the instructions given them on the manufacturer's label or by their caregiver. Short-term use of mild corticosteroid medications is considered safe when directions for use are closely followed. Over-the-counter medications formulated at low concentrations present the least risk when directions for use are followed. For moderate to severe cases of dermatitis these low concentration formulations, however, are unlikely to be sufficient. More potent formulations are often required, and with the rise in potency and duration of use risk of side effects from off-label use or chronic use increases.
Corticosteroid Side Effects
The suppression of natural corticosteroid secretion is one of the most significant risks associated with synthetic steroid use. Synthetic steroids suppress adrenocorticotropic hormone (ACTH) secretion in the same negative feedback loop that involves cortisol, limiting natural adrenal hormone secretion. The synthetic is effectively replacing the natural hormone and interferes with the natural diurnal and episodic rhythm of release. When ACTH is naturally secreted, cortisol release is evident 15 to 30 minutes later. A normal release pattern follows a major burst early in the morning, followed by 7 to 15 episodes per day.
The introduction of synthetic corticosteroids can suppress the natural pathway to an extent dependent upon the dose, the potency of the formulation, the duration of treatment, and how the individual uses the synthetic and their particular response to the medication. Mild formulations are unlikely to cause adrenal suppression; however, over-use or long-term use of the potent topical or systemic formulations raises this risk significantly.
Areas of the body with thin or delicate skin are prone to over-application and side effects from topical corticosteroid use. These areas include the face, groin, and breasts. On the face misapplied corticosteroids have caused acne, redness, and apparent swelling of blood vessels. Strong topical steroids used around the eyes have resulted in cataracts and glaucoma. The carrier base into which a topical steroid is compounded may facilitate increased skin permeability and increase the risk of the steroid affecting internal organs. Overuse, applying over a widespread area of the body, or covering the area of application too tightly and for too long are typical ways corticosteroids are misused and risk the more serious side effects.
Children may be especially prone to side effects because of a larger skin surface area-to-body weight ratio. In children adrenal suppression from long-term use, or overuse of potent corticosteroids can manifest as delayed growth and weight gain, headaches, and low plasma cortisol levels.
Pregnant or nursing women should be carefully instructed on corticosteroid use as topical steroids can permeate the skin, potentially affecting the developing fetus. Corticosteroids applied around the breasts have been found in breast milk. Animal studies examining the effects of corticosteroids on fetal development have prompted the California EPA to caution against the use of the high-potency prednisolone analog, clobetasol propionate, in pregnant or soon-to-be-pregnant women because of potential birth defects. Synthetic glucocorticoids are administered commonly to women pre-term where a danger of respiratory distress syndrome and neonatal death is believed to exist, as this therapy improves lung function in the newborn. Long-term effects, however, may increase the risk of cerebral palsy and alter the developing brain.
Short-term use (two weeks or less) of systemic steroids, such as prednisone, can result in side effects that might include disturbances in sleep, increased appetite and weight gain, and either an increase or decrease in energy levels. Often these side effects will diminish after the conclusion of treatment. Long-term use of the more potent topical or systemic steroids has resulted in thinning skin, skin sensitivity, increased bruising, weakness and tearing of the skin, as well as increased risk of bacterial and fungal infections. Adverse effects are generally found in everyone using systemic steroids for longer than one month.
Chronic overdose can produce a condition clinically identical to Cushing's syndrome, a condition caused by a metabolic overproduction of cortisol. Upper body obesity, marked by "moon" face or a redistribution of fat to the upper body and neck, with thinning of arms and legs, are all symptoms of Cushing's syndrome.
Systemic and long-term use of potent topical corticosteroids must be slowly withdrawn, to allow the hypothalamus-pituitary-adrenal axis to respond to decreasing blood levels of the synthetic steroid and begin to again supply naturally secreted hormones. The abrupt cessation of corticosteroid use, especially after systemic or longer-term use of high-potency topical formulations, can result in acute adrenal crisis. Acute adrenal crisis is a condition clinically similar to Addison's disease, in which disease or injury prevent cortisol production, and is marked by dehydration, severe vomiting, diarrhea, low blood pressure, and loss of consciousness. Acute adrenal crisis can be fatal.
Osteoporosis is another condition that can be induced by prolonged, high-potency steroid use. Prednisone or prednisolone is prescribed for severe psoriasis or severe seborrheic dermatitis to control inflammation. These are also broadly prescribed for treatments beyond dermatological conditions—treating respiratory, eye, blood, and nervous system diseases, to give the broad categories inflammatory diseases fall into. For therapies requiring 7.5 mg or more of prednisone per day for three or more months, osteoporosis is a risk from the bone loss that occurs early in the treatment. Calcium supplements and vitamin D are recommended as a preventative, to be started at the same time as the steroid.
As a general rule, if one's condition warrants the use of any potency of corticosteroid these medications should be used sparingly, and strictly according to the manufacturer's instructions and those given by your dermatologist or health care professional.
Some of the Big Names in Dermatitis Treatment
As mentioned above, clobetasol propionate is a very potent topical prednisolone analog for dermatological use, marketed under the names Clobex™, Cormax™, Olux™, and Temovate™. These products are available in lotions, sprays, shampoos, creams, and ointments. In a 0.05% clobetasol propionate formulation these brands of corticosteroids are categorized as a "Class 1–Superpotent" steroid by the National Psoriasis Foudnation. Other superpotent topical corticosteroids include betamethasone dipropionate (marketed as Diprolene™ ointment), halobetasol propionate (Ultravate™ cream), and fluocinonide (Vanos™ cream).
Betamethasone dipropionate (Diprolene AF™ cream) and fluocinonide (Lidex™ cream) have been formulated to fit lower categories of strength, such as "Class 2–Potent." Some of the other steroids listed in this lower, "potent" class include halcinonide (Halog™ ointment), diflorasone diacetate (Psorcon™ cream, or Florone™ ointment), mometasone furoate (Elocon™ ointment), and desoximetasone (Topicort™). Additional categories of corticosteroids assembled by strength consist of Classes 3 through 5, comprising the mid-strength range, Class 6 mild formulations, and Class 7 the "least potent" class. Many hydrocortisone lotions and creams fall into this last category. Awareness of where on this range of potency a given medication falls is important to avoid accidental overuse and the potential side effects from the higher potency products available.
On the Natural Side of Things
Corticosteroids have become widely accepted and ubiquitous in the treatment of inflammatory conditions for their effectiveness against inflammation. This effectiveness comes with a price, however, as has been described above.
If there are ways to address inflammation through other natural means, the benefits should include a reduction in the use of synthetic steroids and their potential risks. Even for sufferers of moderate to severe psoriasis or eczema, natural means to reduce inflammation can be utilized—even as more potent, less "natural" means are tapered or eliminated. An anti-inflammatory diet, stress reduction, avoidance of environmental triggers, and natural topical anti-inflammatory treatments may all help to limit the use of synthetic steroids.
The goal is to reduce one's symptoms. If synthetic corticosteroids can be relied upon as a "rescue remedy" when flare-ups are difficult to manage otherwise, the inherent risks of these powerful drugs may be minimized. DermaHarmony offers a natural approach that can be used in conjunction with more conventional methods such as corticosteroids. We offer a guided program, with gentle products and support that can be helpful in managing and improving your skin condition. No matter where you are in your healing process, the DermaHarmony approach provides a safe supportive method to be used as adjuncts during conventional treatments, or to facilitate the tapering process, or as a natural alternative.
Finding Natural Relief to Inflammatory Conditions
Whether you have just been diagnosed with an acute skin condition or have been managing your chronic skin inflammatory condition for several years, there are many encouraging alternatives for treating psoriasis, eczema, and dermatitis. An integrative approach can help the juvenile or adult skin inflammation sufferer manage—often reduce—the severity of the condition. A healthy meal plan and avoiding dietary triggers, together with the use of natural herbs and other nutritional supplements, topical gels or ointments, and stress-reducing techniques are all ways to naturally reduce the discomforting symptoms. At DermaHarmony, we understand that each one of us responds a little differently to both the conditions associated with eczema and to different treatments, and we can help you find a solution that works well for you.
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Synthetic Corticosteroids, Natural Corticosteroids, and Your Skin—Reference Documents and Further Reading
Principal Author: C. Lucida, DermaHarmony Science Editor
Date of Publication: 06/01/2010
Article Last Updated: 06/01/2010