CORTICOSTEROIDS Treatment

The newer corticosteroids for local application, betamethasone valerate and fluocinolone acetonide, are so much better than their predecessors that the need to use other routes of administration is diminishing. Lichen planus, lichen simplex and chronic discoid lupus erythematosus respond, particularly if pene­tration of the drug is assisted by the technique of occluding the anointed area with an impervious layer of material such as polythene sheeting. This improve­ment in therapeutic effect, however, has been achieved only by reducing the margin of safety; with the occlusive technique systemic absorption is increased to such a degree that adrenocortical suppression is possible. It is therefore advisable to limit the duration of occlusion to periods of 12 hours; and the area treated at one time must not exceed one-third of the total body surface.

Intra-cutaneous Injection.—Resistant patches of lichenification, lichen planus, discoid lupus erythematosus and psoriasis can be treated by the injection of triamcinolone around the lesions, the total volume used being not more than 0-5 ml. The injections are repeated at weekly intervals until a satisfactory response has been obtained. Small patches of alopecia areata are also suitable for such treatment, but widespread loss of hair cannot be treated by this method.

Systemic Treatment.—Corticosteroids are needed as a life-saving measure in fulminating illness associated with drug eruptions, urticaria and erythema multiforme of the Stevens-Johnson type. The treatment should be started by giving 0.1 g. of hydrocortisone hemisuccinate intravenously and 40 mg. of prednisolone in divided doses by mouth, during the first 24 hours. The dose is adjusted thereafter according to the patient's response; the daily dose should be tailed off and eventually stopped as soon as the activity of the disease has abated—which will probably be within three weeks.

Long-term corticosteroid treatment is required in exfoliative dermatitis, the pemphigus group of diseases, mycosis fungoides, the cutaneous reticuloses and disseminated lupus erythematosus. Since these are mortal diseases or at least endanger life, such treatment is manifestly justifiable. After initial high dosage of the order of 60 mg. of prednisolone daily to achieve control, a main­tenance dose as low as 10 to 15 mg. of prednisolone daily is often possible.

Difficulty arises in deciding whether to use systemic corticosteroid treatment in chronic non-fatal dermatoses, for if such treatment is begun it may have to be continued indefinitely. It is established practice to use oral treatment to tide a patient over a severe attack of urticaria, erythema multiforme or a drug eruption since these are likely to be self-limiting. A severe attack of eczema which is attributable to some remediable stimulus such as contact with a known irritant can reasonably be suppressed during the period of its activity with the prospect of being able to stop the treatment within a few weeks. The management of lichen planus is more debatable since local application of the newer corti-costeroids under occlusion is so effective. Most debatable of all are cases of obstinate and disabling dermatosis when there is some prospect of being able to effect material improvement but at the risk of keeping the patient permanently on corticosteroid treatment. Many dermatologists regard the risk as too great to contemplate in any circumstances; but this is perhaps a somewhat extreme view, and it is not borne out by the experience of those who have used long-term treatment over a period of several years with strict supervision of the patients. It seems probable that if the maintenance dose can be kept at or below 10 mg. of prednisolone daily, and never exceeding 15 mg. daily (except under conditions of stress as mentioned below), the risks are very much reduced and may be accept­able for the few patients who would fall within the terms of the following conditions :

The dermatosis is so severe as to interfere seriously with the patient's life and ability to work, either by reason of physical incapacity or psychological handicap such as an overpowering feeling of inferiority.

A carefully supervised and adequately prolonged period of treatment (say one year) by other means has failed to bring substantial relief.

There is no history suggesting peptic ulceration, psychosis, diabetes mellitus, significant hypertension or severe osteoporosis.

There is no active focus of tuberculosis. A past history of this disease points to the need for a careful clinical and radiological survey and, even if no activity is detectable, anti tuberculous drugs should be given concurrently with corticosteroids. A close watch should be kept during treatment in all cases, irrespective of a known history of tuberculosis, for signs of this disease.

The patient is intelligent and co-operative. He should understand the nature of the risk involved in the treatment and accept it. He should be pre­pared to attend regularly for follow-up, and should carry a corticosteroid treat­ment card which should be kept up to date.

In the case of alopecia treatment should be restricted to those in whom the loss of hair is total, or nearly so; the alopecia should have occurred after puberty, and a wig should have proved unsatisfactory.

It is recommended that the initial daily dose of prednisone should be 15 mg., that, except as mentioned below, this dose should never be exceeded, and that the maintenance dose should be kept at or below 10 mg. daily at a level at which the disease is just active. If worthwhile improvement has not occurred within 12 weeks, the treatment should be abandoned by gradually tailing off the dose. The follow-up needs to be at weekly intervals initially until the disease has been controlled and the dosage stabilized, and thereafter at increasing intervals but never longer than eight weeks. At each visit the patient is assessed clinically, has his blood pressure taken, is weighed and has his urine examined for sugar and albumin. The most serious risk of the treatment is suppression of adrenocortical function which could lead to sudden adrenal failure in face of the stress of an infection, an anesthetic (even a dental gas) or an injury. The. remedy is to cover periods of stress with an increased dose of steroid, say three to four times the normal. The corticosteroid record card is the patient's only safeguard if he is involved in an accident and taken unconscious to hospital.

The method will be found applicable to selected cases of severe atopic eczema (Besnier's prurigo), generalized neurodermatitis and alopecia totalis. Psoriasis is unsuitable (even if triamcinolone, which has been specially recom­mended for this condition, is used) because the maintenance dose is usually above the recommended maximum, and there is also a tendency for the disease to relapse violently when the treatment is stopped.

It is possible that as far as their effect upon diseases of the skin is concerned, some corticosteroids are more effective than others. In pemphigus cortico-trophin injections can be much more effective than oral corticosteroids but this might be due to defective absorption from the gut. In alopecia there is an impression that methyl prednisolone and triamcinolone are more effective than prednisolone in equivalent dosage. On the other hand prednisolone is regarded as safer than triamcinolone.