Cortisone in Dermatology: controversies and side effects

What is cortisone?

Cortisone, and corticosteroids in general, are a group of natural and synthetic hormones similar to cortisol, which is the human hormone produced by the adrenal gland. As they have notable anti-inflammatory and immunosuppressive properties, they are widely used in medicine.

How does cortisone work?

Corticosteroids are naturally produced by the adrenal gland. They can affect the function of any organ or system such as the heart, bones, skin function and muscles, as well as the immune, endocrine and nervous systems. Corticosteroids act by altering carbohydrate, protein and fat metabolism.

The main properties of corticosteroids are:

• anti-inflammatory
• immunosuppressive
• antiproliferative
• vasoconstrictor

Corticosteroids are anti-inflammatory as they block the mediators of inflammation and trigger the formation of anti-inflammatory mediators.
The immunosuppressive function is related to the direct inhibitory action on T lymphocyte activity.
Corticosteroids proliferative function is exerted by directly blocking DNA synthesis and, thus, cell turnover.
Finally, corticosteroids are vasoconstrictors due to the inhibition of vasodilator inflammation mediators such as histidine.
The above functions are harnessed extensively in medicine through balancing doses and varying route of administration.

What are the side effects of cortisone?

Cortisone has many side effects that are mostly related to dosage and duration of administration.

• Neuropsychiatric: at a low dosage, cortisone may result in “steroidal euphoria”. Instead, at high dosage, it will induce anxiety, depression and symptoms of psychosis (steroid-induced psychosis)
• Cardiovascular: increased fluid retention with hypertension mainly due to increased sodium retention function
• Metabolic: inhibition of protein synthesis and increased protein catabolism can result in developmental delay (young children) and osteoporosis (bone fragility). It can also cause changes in fat metabolism, with fat accumulating in the face (“moon face”) and back. Cortisone can also cause increased sweating and sebaceous secretion.
• Endocrine: due to the overproduction of glucose from amino acids hyperglycemia, insulin resistance and diabetes can occur
• Skeletal: risk of osteoporosis due to inhibition from calcium uptake into the bones
• Gastrointestinal: increased gastric acidity with risk of ulceration
• Ocular: increased eye pressure, retinal detachment, early cataracts
• Infectious: due to immunosuppression, risk of infection or the reactivation of a latent infection (TB, hepatitis C)
• Pregnancy: increased risk of teratogenicity (fetal malformation)

The use of cortisone in dermatology

Topical cortisone is often prescribed for inflammatory dermatologic conditions and is applied directly onto injured skin. Cortisone is used in cases of:

• Psoriasis
• Atopic dermatitis
• Seborrheic dermatitis
• Rosacea
• Lichen planus
• Dyshidrosis
• Itchy dermatitis

By exerting its anti-inflammatory, antiproliferative and vasoconstrictive properties, cortisone induces a rapid anti-dermatitis respositive action.

Side effects of topical cortisone

In addition to other more beneficial functions, when applied to the skin, cortisone can provoke side-effects that are particularly negative as they can cause changes in the skin and/or cause other conditions. These include:

• atrophy
• telangiectasias
• stretch marks
• hair growth
• petechial purpura
• perioral dermatitis
• rosacea
• acne
• hyper- or hypo-pigmentation
• sensitivity to light
• tumor degeneration
• spread of infections

For these reasons, among others, the use of topical cortisone must be used sparingly over a very short period. Another limitation is the pharmacological potency of the cortisone used.

Pharmacological potency of synthetic corticosteroids on the skin

Pharmacological potency is one of the parameters used to evaluate the toxicity of various corticosteroids on the skin. This information can then be used to select the most appropriate corticosteroid to use and for how long it should be administered.

• Very high potency: clobetasol propionate; betamethasone dipropionate
• High potency: fluocinonide; halcinonide; mometasone
• Medium-high potency: fluticasone; triamcinolone
• Medium potency: mometasone fluoride; betamethasone valerate
• Medium-low potency: alclometasone dipropionate; desonide
• Low potency: hydrocortisone

As a rule of thumb, the greater pharmacological potency, the greater toxicity, meaning that the duration of treatment should therefore be limited and vice versa.

Cortisone dependency

A major and, likely, the most dreaded side effect of cortisone is addiction. When applied to the skin, cortisone basically acts just as a drug would. Cortisone dependency – whereby the individual can no longer live without it – quickly sets in, sometimes as early as within a week of treatment.
This dependency becomes very evident when the individual tries to stop cortisone and a rebound occurs.

Tachyphylaxis

Tachyphylaxis is something that can happen with all drugs. It occurs when the body develops a reduced response to a drug, which means it will likely require a higher dose or more frequent administrations to achieve the same effect. In other words, an individual who has started applying cortisone once in a while to control dermatitis, will soon realize that in order to achieve the same result, they must continually increase the frequency of application (or the dose applied). Tachyphylaxis immediately leads to toxicity.

Rebound

Viene detto Rebound il fenomeno per cui dopo la sospensione del cortisone si ​​Rebound refers to the phenomenon whereby, after discontinuing cortisone, there is a sudden worsening of the dermatitis for which the product had been prescribed. The severity of the rebound will relate to the potency of the cortisone used and the duration of use. Without the correct guidance, rebound is the main reason why an individual remains dependent on cortisone.

Withdrawal

For many individuals, the discontinuation of cortisone not only causes rebound (worsening of original dermatitis) but also provokes more general malaise with symptoms including fatigue, agitation, insomnia, loss of appetite, sweating and tremors, etc. In other words, cortisone withdrawal is not dissimilar to that of other drugs and, similarly, the individual needs help and support to overcome it.

Red skin syndrome (RSS)

Red skin syndrome (RSS) can creep up in those who have been treating dermatitis with either topical or systemic cortisone for some time.
At first, RSS appears to be a simple worsening of the dermatitis, for which the individual applies more cortisone. Suddenly, all or most of the skin will become bright red, often accompanied by exudation, the formation of cuts, intense itching and a strong burning sensation. Alongside these symptoms, the patient will feel general malaise, including agitation, feeling cold, exhaustion and fever. It is a severe, acute condition where the skin can become quickly infected and the infection transmitted internally. The individual will often require hospitalization to monitor and maintain vital parameters.

Systemic cortisone treatments

Cortisone can be prescribed systemically to treat dermatitis and is available in either tablet or liquid form. Sometimes, systemic and topical treatment can be used simultaneously.
Systemic cortisone can cause the same adverse reactions on the skin and can worsen dermatitis in the same way that topical treatments do, but will provoke these side-effects much more quickly.
In addition, if the individual is in topical steroid withdrawal, but is prescribed systemic cortisone for other reasons, their dependence on cortisone will re-emerge and they will need to begin a course of treatment to overcome this dependency all over again.

Topical steroid withdrawal (TSW)

Withdrawal from cortisone causes varying degrees of skin distress. The severity of distress caused will partly depend on the duration of cortisone use, the extent to which it was applied and the potency used.
As soon as the dermatologist diagnoses cortisone dependency, the goal should be to immediately assist the individual in overcoming rebound and withdrawal in order to reduce the risk of red skin syndrome, which could appear at any time.

Rebound and withdrawal during TSW

After cortisone withdrawal, the onset of withdrawal symptoms will likely appear within seven to ten days. This is due to the fact that the skin retains any residual cortisone and uses it up during this time period.

Duration of rebound and withdrawal

There is considerable variability in the duration of rebound and withdrawal due to many factors such as the type of dermatitis for which cortisone was used, the potency of cortisone used, extent of application site, and the duration of application. In general, symptoms of rebound and withdrawal last for at least one month and can sometimes persist for over a year.

How to assist an individual in rebound and withdrawal

The first obligation of the dermatologist is to convince the individual to go through rebound and withdrawal. To do so, it is important that the individual fully understands that continuing with cortisone is dangerous and will cause greater problems in the future. It is crucial to explain to them that, once withdrawal is over, the dermatitis can finally be cured and sent into remission. It is crucial to understand that during the acute crisis period of the rebound phase, the skin will not tolerate the application of any product. Any attempt to apply products to the skin is followed by a further worsening of the condition. Similarly, wetting or washing the area with dermatitis must be suspended, as this will also stress the skin. To at least partially reduce itchiness, control exudation and prevent infection, apply moist cold compresses in potassium permanganate.
If the dermatitis is extensive, potassium permanganate solution should be used to ‘dry’ wash the entire body, including the head.

The exudative phase

The phase begins upon the discontinuation of cortisone and is characterized by the exudation of serum droplets, a sticky liquid that emerges from the skin. The duration of this phase is particularly variable and unpredictable, but for however long it lasts, it’s important to use moist cold compresses with potassium permanganate solution in order to keep the body clean. In addition to preventing skin infection in this delicate phase, this disinfectant has astringent properties that help limit and stop exudation altogether.

Red skin syndrome

Once the exudative phase is over, red skin syndrome follows, causing the skin to become completely red. At the same time, symptoms of intense burning accompany feelings of cold due to heat loss from the inflamed skin.
At this point, the only product that is proven to be tolerated and help the patient toward healing is PEG Ointment with allantoin.
PEG Ointment originated as a healing agent for ulcers and wounds but, in DermaClub’s experience, it is the only product that can be applied to soothe the skin during rebound and withdrawal. In the more acute stages of rebound and withdrawal, even PEG Ointment will not be tolerated. If this occurs, wait a few days without applying any product to the affected areas before trying again. Repeat until PEG Ointment is not only tolerated, but is providing clear benefit to the individual.
By continuing with ‘dry’ washes and PEG Ointment, the withdrawal phase will come to a close. From there, the treatment of the original dermatitis can begin using non-corticosteroid products that should have been used from the start.