38 PRACTICAL DERMATOLOGY JANUARY 2013

FEATURE STORY
C
orticosteroids have long been used in medical prac-
tice for the management of inflammation. In der-
matology, they play a pivotal role in interventions
for various conditions, such as atopic dermatitis and
psoriasis. And yet, despite their status as a mainstay treat-
ment, steroids in general have certain baggage, due in part
to public perception with the name to their clinical use in
therapy for nearly six decades. According to James Dinulos,
MD, who practices at Dermatology and Skin Health in
Dover, NH and is Clinical Assistant Professor of Dermatology
at the University of Connecticut, despite some advances
in the research and treatment of various diseases in recent
decades, corticosteroids remain essential to the treatment of
many dermatologic conditions. Ahead, Dr. Dinulos discusses
the latest trends and advances regarding corticosteroids.
There has been some research suggesting a high
prevalence of corticosteroid phobia. What do
you make of the report and do they influence
your practice?
There is no doubt that steroid phobia exists, notes Dr.
Dinulos. Smaller children may be too young to be fearful of
certain agents, but Dr. Dinulos points out that older kids
as well as their parents often have a phobia toward ste-
roids. Given that parents tend to be the ones applying the
medications in many of our pediatric patients, most of our
interaction about the safety of steroids will likely be with
parents, he continues.
Addressing steroid phobia can be a challenge with
some particularly resistant parents, but Dr. Dinulos
observes that setting the appropriate context is key toward
helping them understand the adverse event profile of ste-
roids. I usually tell the patient or parent that these agents
have been used for roughly 60 years and that just by sheer
numbers and time we know that they are safe, says Dr.
Dinulos. But just like any other medicine, there are poten-
tial side effects when steroids are not used appropriately,
and Dr. Dinulos stresses the importance of discussing these
in a fair manner, as well. Often when patients think about
side effects of medications, theyre not weighing the risks
of potential side effects against the risks of non-treatment,
he notes. The adverse effects of unopposed inflammation
in dermatologic conditions such as atopic dermatitis or
psoriasis can be devastating, he says. When patients or
parents refuse to treat one of these conditions because of
Corticosteroids
in Dermatology:
Whats Old Is New
A Q&A with James Dinulos, MD
The adverse effects of unopposed
inflammation in dermatologic
conditions such as atopic dermatitis
or psoriasis can be devastating, says
Dr. Dinulos.
JANUARY 2013 PRACTICAL DERMATOLOGY 39
FEATURE STORY
concern about systemic absorption, Dr. Dinulos empha-
sizes the consequences of uncontrolled inflammation and
its impact on overall health.
Studies have been done on heart disease showing that
psoriatic patients, for example, are at increased risk for
myocardial infarction, presumably from uncontrolled
inflammation, he continues. Thats why it is important to
control inflammation, he stresses. Whenever I talk about
a side effect of a medication, especially steroids, I try to
make sure its a balanced discussion of risks and benefits.
Patients are more likely to be hyper-aware of the steroidal
side effects but may not be as aware of the consequences
of not treating inflammation, observes Dr. Dinulos.
Has steroid phobia affected how clinicians
themselves may be treating inflammation, per-
haps in cases of particularly resistant patients/
parents?
For dermatologists, the notion of steroid phobia is well
accepted, says Dr. Dinulos. How to talk to parents who
are treating their children that want to know more about
adverse events can be a challenge, however. Truth be told,
treating the inflammatory response with glucocorticoids
can improve barrier function and diminish the risk for
secondary bacterial infection. This also applies for emol-
lients, observes Dr. Dinulos, but improving barrier function
with emollients alone is not realistic. At the same time, Dr.
Dinulos explains, There is a tipping point with steroid use,
where the AD or psoriasis may resolve but you get a nega-
tive impact from diminished collagen production. The art
of medicine comes in with how we can judge a patients
response and tailor a therapeutic regimen that minimizes
risks while maximizing efficacy of the agents.
Perhaps a symptom of steroid phobia is what Dr.
Dinulos calls the unwritten two-week rule of steroid
treatment. Some clinicians will stop glucocorticoid treat-
ment after two weeks as a general rule, perhaps to avoid
side effects, he says. The problem with this logic, Dr.
Dinulos suggests, is that it doesnt focus enough on the
patients clinical response. The impact of a given agent,
both from the standpoint of safety and efficacy, should
be weighed by its impact on the disease state, he notes.
Many inflammatory conditions are not curable, he argues.
Steroidal agents are effective at controlling these dis-
ease states. Patients cannot be on them all the time, but
their time on them should depend on response and dis-
ease state rather than on an arbitrary duration, says Dr.
Dinulos.
Dr. Dinulos points out that clinicians can get creative
with incorporating agents such as calcipotriene to limit
the amount of steroids used. This is called chronic long-
term flare maintenance, which basically holds that you use
higher potency glucocorticoids for flares and then main-
tain response and limit the severity of the glucocorticoid
and increase time between flares with agents such as tacro-
limus and pimecrolimus, or even ceramide-based creams.
This model has been studied and proven successful, says
Dr. Dinulos. By being disease-state oriented, we can limit
exposure to all of these medications, he observes.
Finally, in terms of compromising with resistant parents,
Dr. Dinulos imparts that it is important to treat a disease
within the context of a patient or parents own belief sys-
tems. This may not always result in the most optimal treat-
ment, but it is more important to have patients agree to
some kind of intervention rather than nothing at all. That
doesnt mean that a parent cannot be swayed, however, if
you provide enough reason within that belief system, says
Dr. Dinulos. Some parents want only natural treatments
for their children and consider steroids to be unnatural.
In these cases, sometimes a compromise is not possible.
However, that can present a pathway to discussing the
effects of uncontrolled inflammation, but perhaps from
another perspective. You can perhaps discuss how a child
at one year old may be discouraged to learn and explore
as they should when they are constantly scratching and
itching. If you explain to a parent that not treating a childs
inflammation can negatively impact a childs cognitive and
motor development, the parent may be more receptive to
the notion of steroids, notes Dr. Dinulos.
What are important steps for minimizing risks of
common adverse events? When adverse events
do occur, are there common contributory factors?
The first thing that clinicians should do to minimize adverse
events, according to Dr. Dinulos, is to select an agent with
the least likelihood of side effects for patients. Particularly
in pediatric patients, realizing that there are other factors,
such as increased absorption from diapers are important
and should be considered, he adds. After agent selec-
tion, you want to treat at appropriate strength, which will
vary based on the specific circumstances of each case, Dr.
Dinulos reminds.
Another crucial element to reducing any unwanted
effects from treatment and for maximizing efficacy is
to provide careful instruction on how to apply steroids.
Sometimes you have to demonstrate how to apply the
cream and then watch the parent do it, says Dr. Dinulos.
How an agent is appliedeither by dabbing or rubbing
can affect the dosage of the drug the patient is actually
receiving. If a lower-strength steroid is not working, you
must first determine if the steroid has been applied appro-
priately before changing the course of treatment, notes
40 PRACTICAL DERMATOLOGY JANUARY 2013
FEATURE STORY
Dr. Dinulos. Again, this will depend on how well you know
the patient and their compliance patterns.
When side effects do occur, its usually from clinicians
who inadvertently use a super potent corticosteroid in a
child, says Dr. Dinulos. The most common side effect we
see in pediatrics is skin thinning and epidermal atrophy,
which thankfully most of the time resolves in pediatric
patients. They also improve with time in older patients,
but at a slower rate, Dr. Dinulos explains. Another poten-
tial side effect can occur when using steroid around the
eyes. Patients can get glaucoma and cataracts with long-
term use of steroids near the eyes, but thankfully this is
fairly rare. Nevertheless, its a severe potential side effect,
and clinicians should exercise restraint in these areas.
Another side effect Dr. Dinulos sees more in girls than
boys is stria formation. This has likely to do with periods
in a persons life when the hormonal status is changing,
he says. As with any other stretch mark, stria formations
improve with time but are permanent.
There is also some research about corticoste-
roids impairing barrier function and possibly
having a negative effect on collagen produc-
tion. Could you offer some clinical context for
these findings?
There has been a lot of relevant research over the last
10 years roughly thats looked at lipid biosynthesis and
the lipid content of the epidermis. This has led to a
greater emphasis on ceramides, which has translated into
newer creams, often called barrier repair agents, Dr.
Dinulos explains. Barrier repair products have taken two
approaches, notes Dr. Dinulos. The first is to be approved
as a medical device, with ceramides dispersed in the
appropriate ratios. Among these products are Epiceram
(Promius), Mimyx (Stiefel/GSK), Hylatopic Plus (Onset
Dermatologics), Atopiclair (Sinclair), and Eletone (Mission
Pharmacal). The other path is the more commercial route,
with agents such as CeraVe (Valeant) and Restoraderm
(Galderma) that incorporate lipids into moisturizers, says
Dr. Dinulos.
While these agents can be exploited to the benefit of
patients and physicians, Dr. Dinulos sees barrier repair
agents as complimentary to steroids, rather than displac-
ing them. In chronic long-term flare maintenance, barrier
creams represent a way to help diminish inflammation in
the skin and thereby serve a potential function as part of a
long-term regimen, he says.
There has been some discussion about pediatric
labeling for corticosteroids. Can you clarify the
issue from a technical standpoint? Is this
clinically relevant?
Dr. Dinulos believes that pediatric labeling is important for
one critical reason. We all know that with many of the
medications that were using, the vast majority have not
been studied in the pediatric population, he notes. Thus,
with almost any medication you choose, youre going off-
label. With a drug that has been studied and approved, it
becomes extremely relevant to study with further trials, for
these reasons. Dr. Dinulos notes that fluticasone has been
studied in three month olds, and it is likely to be used more
readily in this population than those that have not been
studied.
Given that pediatric studies are not as feasible for many
manufacturers, Dr. Dinulos recommends that clinicians be
mindful when administering any medicationdermato-
logic or otherwiseto an infant. Kids are not little adults,
and thats why pediatric labeling for steroids is probably
a benefit to both patients and physicians, he observes.
It may also help to curb the problem of under-treatment
of infants, he adds. Perhaps because of a lack of pediatric
indications, many infants suffer and go without treatment,
so pediatric labeling may help to prevent this, as well, says
Dr. Dinulos.
What is your take-away message about the sta-
tus and importance of corticosteroids in the
realm of managing inflammatory dermatologic
conditions?
Sometimes keeping things simple is the best approach for
a given condition. Steroids are still the standard of care
in many conditions, says Dr. Dinulos. Other than trying
to manipulate or combining steroids with steroid-sparing
agents or tweaking the vehicle, we havent had many
new molecules for topical application in dermatology for
roughly a decade. However, he continues, though there
is little thats new, on the other hand, if we stick to the
basics of talking to our patients about the importance of
managing inflammation, we can continue to control these
conditions, he observes. So in a sense, he notes, whats
old is new again. n
Sometimes keeping things simple is
the best approach for a given
condition. Steroids are still the
standard of care in many
conditions, says Dr. Dinulos.