Minimizing Complications from Systemic Glucocorticosteroid Use

Molecular marker identification, antioxidant, antinociceptive, and anti-inflammatory responsiveness of malonic acid capped silver nanoparticle

Nano-sized silver has drawn a great deal of attention in the field of health sciences owing to its remarkable therapeutic applications. Interestingly, the method applied to synthesize nanoparticles and the choice of reagents considerably influence their therapeutic potential and toxicities. Current research has explored the toxicity, anti-inflammatory, antinociceptive, and antioxidant responses of the malonic acid-capped silver nanoparticles (MA-AgNPs (C) by using sodium borohydride as a reducing agent at low temperatures by employing both in vitro and in vivo approaches. Furthermore, it has highlighted the synergistic effect of these novel compounds with conventional anti-inflammatory therapeutic agents. Acute and sub-acute toxicity analysis performed following OECD guidelines showed that the studied MA-AgNPs (C) are safer, and prominent toxic signs have not been detected at the highest studied dose of 2,000 mg/kg. Cytotoxicity evaluation through brine shrimp lethality revealed 20% lethality at the highest concentration of 169.8 μg/mL. Significantly, positive anti-inflammatory and analgesic responses alone as well as synergism with the standard were identified through in vitro as well as in vivo methods which were more potent at a lower dose (200 mg/kg). Notably synergistic outcomes were more pronounced than individual ones, indicating their prominent effect as a feasible drug delivery system. IL-6 and TNF-α assessment in excised paw tissue through RTPCR technique further supported their anti-inflammatory potential. DPPH assay revealed eminent in vitro antioxidant activity which was further corroborated by in vivo antioxidant assessment through evaluation of SOD in excised paw tissue.

A novel therapeutic approach for reducing postoperative inflammatory complications after impacted mandibular third molar removal

BACKGROUND

This study was designed to compare effect of combined use of dexamethasone and honey versus each agent alone in controlling complications associated with removal of impacted mandibular third molar.

METHODS

This randomized clinical study included patients suffering from impacted mandibular wisdom teeth. Patients were divided randomly into 4 groups. Group I, control, group II, received dexamethasone injection preoperatively, group III, received honey locally in the wound after extraction, and group IV, received dexamethasone injection preoperatively and topical honey application. All patients were evaluated preoperatively and postoperatively to assess facial edema, interincisal distance, pain, and total analgesic dose used.

RESULTS

Significant edema developed in group I than other groups and improved significantly in group II and III on seventh postoperative day, and tenth postoperative day in group I. Insignificant edema developed in group IV. Significant decrease in interincisal distance occurred in all groups on third postoperative day that improved significantly on seventh postoperative days in all groups except group I, it improved on tenth postoperative day. Pain was significantly minimum in group IV than other groups and its maximum degree was in group I.

CONCLUSION

Both dexamethasone and honey are an effective way of minimizing swelling, pain, and trismus after removal of impacted lower third molars. Both agents either alone or in combination provide simple, safe, painless, and cost-effective method to eliminate postoperative discomfort. However, dexamethasone or honey can decrease complications related to surgical extraction of mandibular third molar, the simultaneous application of both agents is more effective method in this regard.

Systemic Corticosteroid Therapy for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in Vietnam: Clinical Evaluation and Analysis of Serum Cytokines

Abstract BACKGROUND: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis are severe cutaneous adverse drug reactions. There are some immunological and genetic factors which are believed to be involved in the pathogenesis of SJS/TEN. The treatment of SJS/TEN is still controversial in which several studies showed variable results. AIMS: To evaluate clinically the efficacy of systemic corticosteroid and to analyze some related cytokines in the treatment of SJS/TEN. METHODS: This open, pilot and uncontrolled study was conducted at National Hospital of Dermatology and Venereology, in Hanoi, Vietnam, from October 2017 to September 2019. Methylprednisolone was indicated from the first day of hospitalization with the dose of 0.5-2.5 mg/kg/day (calculated according to prednisolone dose) once daily. It was continued until the patients got re-epithelialization. The efficacy of methylprednisolone was evaluated by observing clinically and analyzing related cytokines before and after the treatment. RESULTS: The mean time of re-epithelialization was 15.9 days, of hospitalization was 15.9 days (range 5-30 days). There was no in-hospital mortality in this study. The most common complication was transient glycaemia (40.6%), there was no patient with sepsis. At the day of hospitalization, serum concentrations of TNF-α, IFN-γ, IL-2, IL-5, IL-13 and IL-10 were significantly higher than those at the day of re-epithelialization (p<0.05). Serum levels of IL-4, did not have significant differences between two time points (p>0.05). CONCLUSION: The systemic corticosteroid is a good choice in the treatment of SJS/TEN. It can reduce serum levels of some cytokines that help SJS/TEN patients with avoiding mortality.

A Comprehensive Review of Therapeutic Approaches Available for the Treatment of Dermatitis

BACKGROUND

Dermatitis or eczema is a prevalent skin disorder worldwide and is also very common as a pediatric inflammatory skin disorder. Its succession gets worse with the multiple comorbidities which exhibit mechanisms that are poorly understood. Its management further becomes a challenge due to the limited effective treatment options available. However, the Novel Drug Delivery Systems (NDDS) along with new targeting strategies can easily bypass the issues associated with dermatitis management. If we compare the active constituents against phytoconstituents effective against dermatitis then phytoconstituents can be perceived to be more safe and gentle.

OBJECTIVE

Administration of NDDS of plant extract or actives displays improved absorption behavior, which helps them to permeate through lipid-rich biological membrane leading to increased bioavailability. The newer efficient discoveries related to eczema can face various exploitations. This can be intervened by the subjection of patent rights, which not only safeguard the novel works of individual(s) but also give them the opportunity to share details of their inventions with people globally.

CONCLUSION

The present review focuses on the available research about the use of nanoformulations in the topical delivery. It further elaborates the use of different animal models as the basis to characterize the different features of dermatitis. The review also highlights the recent nanoformulations which have the ability to amplify the delivery of active agents through their incorporation in transfersomes, ethosomes, niosomes or phytosomes, etc.

Commonality of the IL-4/IL-13 pathway in atopic diseases

INTRODUCTION

Allergy results from an aberrant Type 2 inflammatory response, triggered by a wide range of environmental antigens (allergens) that lead to various immune responses, culminating in the production of immunoglobulin E (IgE). Two key cytokines, interleukin (IL)-4 and IL-13, are critical to the induction and perpetuation of the Type 2 response, and have been implicated in multiple atopic diseases. Area covered: This review summarizes recent milestone developments that have elucidated components of the pathogenesis of atopic diseases such as atopic dermatitis (AD), asthma, and chronic sinusitis with nasal polyposis (CSwNP). Expert commentary: Several therapeutic agents that selectively target potentiators of the Type 2 pathway have shown efficacy in one or more of these atopic diseases, but few agents have proven to be broadly applicable across all three atopic diseases. Dupilumab, a human monoclonal antibody that simultaneously inhibits signaling of IL-4 and IL-13, has demonstrated significant clinical efficacy in AD, asthma, and CSwNP. The fact that these diseases often occur as comorbidities and respond to the same therapy suggests that there is a common underlying pathogenic pathway, and that IL-4 and IL-13 cytokines are central to regulating the pathogenesis of these atopic diseases.

Skin manifestations of Cushing's syndrome

Among the most common diagnostic manifestations of Cushing's syndrome (CS) are those involving the skin; they include violaceous striae, facial acne, hirsutism, acanthosis nigricans (AN), fungal infections, hyperpigmentation (Hp) and easy bruisability. Fortunately, most resolve within a year or two after cure of CS, although light-colored striae can persist for years depending on the age of the patients. AN, Hp, and bruisability usually resolve within months after cure in almost all ages. Facial plethora (along with acne and other facial skin changes) is a typical sign of CS that is due to increased perfusion. It resolves immediately after curative therapy of CS. Typically, the severity of the manifestations does not correlate with the biochemical indices of the disease, pointing to age, gender, genetic and skin-type differences that determine the cutaneous manifestations of CS.

Targeting key proximal drivers of type 2 inflammation in disease

Systemic type 2 inflammation encompassing T helper 2 (TH2)-type responses is emerging as a unifying feature of both classically defined allergic diseases, such as asthma, and a range of other inflammatory diseases. Rather than reducing inflammation with broad-acting immunosuppressants or narrowly targeting downstream products of the TH2 pathway, such as immunoglobulin E (IgE), efforts to target the key proximal type 2 cytokines - interleukin-4 (IL-4), IL-5 and IL-13 - represent a promising strategy to achieve therapeutic benefit across multiple diseases. After several initial disappointing clinical results with therapies targeting IL-4, IL-5 or IL-13 in asthma, applying a personalized approach achieved therapeutic benefit in an asthma subtype exhibiting an 'allergic' phenotype. More recently, efficacy was extended into a broad population of people with asthma. This argues that the Type 2 inflammation is broadly relevant across the severe asthma population if the key upstream drivers are properly blocked. Moreover, the simultaneous inhibition of IL-4 and IL-13 has shown significant clinical activity in diseases that are often co-morbid with asthma - atopic dermatitis and chronic sinusitis with nasal polyps - supporting the hypothesis that targeting a central 'driver pathway' could benefit multiple allergic diseases.

Bolus administration of steroid therapy is more favorable than the conventional use in preventing decrease of bone density and the increase of body fat percentage in patients with inflammatory bowel disease

INTRODUCTION

The effects of short course of corticosteroids on the metabolic processes and bone formation has not been well studied. Our aim was to compare the efficacy, the side effects and the bone and lipid metabolisms in IBD patients using bolus or conventional tapering of methylprednisolone for 12 weeks.

PATIENTS AND METHODS

Nineteen IBD patients received intravenous methylprednisolone of 1mg/kg for 5 days tapered by 4 mg per week. Patients were prospectively randomized in two groups. In "conventional" group (I) steroids were given daily. In "pulse" group (II) weekly doses of steroids were given on special days of the week. The body mass index (BMI) was measured before and after the corticosteroid therapy. Blood samples were collected to assess glucose level, electrolytes, cholesterol and triglyceride levels, inflammatory parameters, cortisol, osteocalcin and crosslaps values. Total body composition analysis was performed at the beginning and at the end of the steroid therapy.

RESULTS

In Group I, BMI increased, total body bone density decreased significantly at the end of the steroid therapy. Body fat percent showed a tendency to be higher at the end of steroid therapy in Group I. Cholesterol level increased significantly in Group I patients. The decrease in serum cortisol level was more remarkable in Group I vs. Group II after steroid therapy. Less side-effect occurred in Group II vs. Group I.

DISCUSSION

Our results suggest that bolus tapering of corticosteroids may have more favorable short term outcome than conventional tapering that may revolutionize steroid therapy in IBD.

Glenohumeral joint injections: a review

Context:

Intra-articular injections into the glenohumeral joint are commonly performed by musculoskeletal providers, including orthopaedic surgeons, family medicine physicians, rheumatologists, and physician assistants. Despite their frequent use, there is little guidance for injectable treatments to the glenohumeral joint for conditions such as osteoarthritis, adhesive capsulitis, and rheumatoid arthritis.

Evidence Acquisition:

We performed a comprehensive review of the available literature on glenohumeral injections to help clarify the current evidence-based practice and identify deficits in our understanding. We searched MEDLINE (1948 to December 2011 [week 1]) and EMBASE (1980 to 2011 [week 49]) using various permutations of intra-articular injections AND (corticosteroid OR hyaluronic acid) and (adhesive capsulitis OR arthritis).

Results:

We identified 1 and 7 studies that investigated intra-articular corticosteroid injections for the treatment of osteoarthritis and adhesive capsulitis, respectively. Two and 3 studies investigated the use of hyaluronic acid in osteoarthritis and adhesive capsulitis, respectively. One study compared corticosteroids and hyaluronic acid injections in the treatment of osteoarthritis, and another discussed adhesive capsulitis.

Conclusion:

Based on existing studies and their level of evidence, there is only expert opinion to guide corticosteroid injection for osteoarthritis as well as hyaluronic acid injection for osteoarthritis and adhesive capsulitis.

Canadian hand dermatitis management guidelines

BACKGROUND

Hand dermatitis (HD) is one of the most common skin conditions; however, it is not a homogeneous disease entity. The severity of HD may range from very mild cases to severe chronic forms, which may result in prolonged disability and, occasionally, refractory HD. Chronic hand dermatitis (CHD) is associated with a high health- economic burden and significant loss of quality of life.

OBJECTIVE

Although numerous treatment options are available, the management of CHD is often difficult and unsatisfactory. There is a paucity of well-designed, randomized, controlled clinical trials in support of the efficacy of established treatment modalities.

CONCLUSION

These guidelines cover the epidemiology, burden, quality of life, etiology, diagnosis, classification, and prevention of HD and provide guidance on management using an approach that is as evidence based as possible.

Controlled release of dexamethasone from subcutaneously-implanted biosensors in pigs: localized anti-inflammatory benefit without systemic effects

Chronically implanted biosensors typically lose sensitivity 1-2 months after implantation, due in large part to the development of a collagen-rich capsule that prevents analytes of interest from reaching the biosensor. Corticosteroids are likely candidates for reducing collagen deposition but these compounds have many serious side effects when given over a prolonged period. One method of assessing whether or not locally released corticosteroids have a systemic effect is to measure cortisol concentrations in venous serum. We hypothesized that a very low release rate of the potent corticosteroid, dexamethasone, would lead to a localized anti-inflammatory effect without systemic effects. We found that reduction in subcutaneous granulocytes (primarily eosinophils), and to a lesser extent, reduction of macrophages served as a good local indicator of the steroid effect. When released over a 28-day period, a total dexamethasone dose of < or =0.1 mg/kg led to a consistent reduction in the number of granulocytes and macrophages found in the local vicinity of the implant without a reduction of these cells at distant tissue locations. The lack of suppression of serum cortisol with these doses confirmed that low-release rates of dexamethasone can lead to consistent local anti-inflammatory effects without distant, systemic effects. (c) 2010 Wiley Periodicals, Inc. J Biomed Mater Res, 2010.

Childhood psoriasis: a study of 137 cases from central China

BACKGROUND

Childhood psoriasis is common, but it has not been adequately reported in China. This study was undertaken to evaluate the epidemiological and clinical findings in children with psoriasis treated in a 9-year period and to compare the data with those from other studies.

METHODS

The data were from 137 children (< or =14 years old) with psoriasis registered in two tertiary hospitals in Wuhan, China between January 2000 and December 2008. They were retrospectively studied.

RESULTS

Of the 137 patients, aged between 3 and 14 years, 64 were males (46.7%) and 73 females (53.3%). Eleven patients (8%) had a family history of psoriasis. Infection was the most common precipitating factor (39, 28.5%). Seasonal influence was found in 57 patients (41.6%). Exacerbations in winter and spring were noted in 29 and 16 patients respectively. Plaque psoriasis was the most common type (72 patients, 52.6%), followed by guttate psoriasis (35, 25.5%), psoriasis pustulosa (15, 10.9%), and psoriasis erythroderma (7, 5.1%). The scalp was the most common initial site affected (69, 50.3%). Nail changes were found in 35 patients (25.5%), but no mucosal involvements were observed. Five patients had arthralgia and two showed abnormal X-ray appearance. Most of the affected children had pruritus. The co-morbidities of childhood psoriasis included allergic contact dermatitis (31, 22.6%), eczema (6, 4.3%), vitiligo (5, 3.6%), and alopecia areata (3, 2.2%). Psoriasis was sometimes misdiagnosed as dermatitis seborrheica (11, 8.0%), neurodermatitis (9, 6.6%) and balanitis (7, 5.1%). Some patients were treated with steroids, but there were obvious side-effects after longterm administration. Thiamphenicol was effective in the treatment of refractory psoriasis pustulosa in children.

CONCLUSIONS

Our findings differ from those of previous studies, showing a lower rate of family history and a higher incidence of severe psoriasis. Differential diagnosis should be made especially when lesions occur at the scalp, elbow or balanus. Allergic contact dermatitis takes place more frequently in children with psoriasis than in normal children. Systemic corticosteroids should not be routinely used and other safer and more effective treatments are needed for severe cases.

Mycophenolate in dermatology

Originally used to treat psoriasis nearly three decades ago, mycophenolic acid, reformulated as mycophenolate mofetil (MMF), has been rediscovered by the world of dermatology. As a relatively well-tolerated immunosuppressive used in organ transplant recipients, MMF has recently been reported to show promise for several dermatologic conditions, including psoriasis, pemphigus vulgaris, pyoderma gangrenosum, bullous lichen planus, and even connective tissue diseases such as lupus erythematosus and dermatomyositis. Although not intended to be exhaustive, this review discusses MMF with regard to its basic pharmacology, its side effects, and its reported efficacy in a variety of dermatologic indications. Relevant literature was retrieved by a Medline search combining the terms "mycophenolate" or "mycophenolic acid" and "skin" or "skin disease" or a number of specific conditions ("psoriasis", "dermatitis", "eczema", "pemphigoid", "pemphigus", "vasculitis", "pyoderma gangrenosum", "Crohn's disease", "graft-versus-host disease", "lichen planus"). As MMF has only been recently re-introduced for dermatologic application, the nature of much of the literature is admittedly that of case reports or case series. Nevertheless, the results are sufficiently promising to warrant further larger, control studies.

Managing adverse effects of disease-modifying agents used for treatment of multiple sclerosis

BACKGROUND

First-line agents approved in the United States for treatment of relapsing multiple sclerosis (MS) include intramuscular interferon beta (IFNbeta)-1a, subcutaneous (SC) IFNbeta-1a, SC IFNbeta-1b, and SC glatiramer acetate. Intravenous mitoxantrone is the only agent approved for secondary progressive MS, progressive relapsing MS, and worsening relapsing MS. Intravenous natalizumab is approved for relapsing forms of MS generally in patients who have an inadequate response to, or are unable to tolerate, first-line therapies. Corticosteroids are commonly used to treat relapses. This paper reviews the incidence and management of common adverse events (AEs) associated with these treatments.

METHODS

MEDLINE and EMBASE were searched for clinical trials and other publications between 1985 and 2007 reporting AEs associated with MS therapies, using these search terms: multiple sclerosis, interferon, Avonex, Betaseron, Rebif, glatiramer, copolymer 1, Copaxone, mitoxantrone, natalizumab, adverse events.

RESULTS

A class-specific flu-like syndrome associated with IFNbeta can be managed through initial dose escalation and administration of analgesics and antipyretics, prophylactically or symptomatically. Injection-site reactions can occur in patients receiving injectable therapies, particularly SC IFNbeta or glatiramer acetate. The greatest risk to patients receiving mitoxantrone is cardiotoxicity; thus, the cumulative dose is limited. Allergic reactions occur rarely with natalizumab, and there is a potential risk of progressive multifocal leukoencephalopathy. AEs associated with short-term pulse corticosteroid therapy are usually transient and largely resolve after treatment is completed.

CONCLUSIONS

To improve adherence to therapy, it is important to educate patients regarding AEs and to manage AEs proactively.

Side Effects of Short-Term Oral Corticosteroids

Background:

Physicians frequently prescribe short-term corticosteroids (CSs) to treat acute and self-limiting diseases. Standard texts and articles do not usually discuss the possible, although infrequent, risks of short-term CSs.

Objective:

To demonstrate that side effects, although uncommon, can occur with short-term CSs and that these can occasionally be serious.

Methods:

Medline peer review literature in English (1985–2006) was searched to identify the potential risks of CSs. Standard textbooks of dermatology, gastroenterology, ophthalmology, pharmacology, respirology, and rheumatology were reviewed. Because the results showed some factual discordance and a dearth of precise data, the results for each body system were reviewed with two relevant clinical specialists at North York General Hospital (with at least 20 years' experience). Further information was obtained from a questionnaire of 200 physicians in North York General Hospital and by feedback from an additional 100 physicians during a presentation of this material at the American Academy of Dermatology.

Results:

Short-term CSs are generally safe, but there have been numerous reports of associated avascular necrosis and a few cases of fatal varicella-zoster in immunocompetent patients. Severe mood changes and psychotic reactions rarely occur unpredictably with short-term CSs. These events are rare, and most treatments with short-term CSs are problem free.

Conclusions:

Problems are infrequent, but patients must be informed of all material risks and treatment options. Thorough chart documentation is required, and patient consent must be given. CS doses should be as low as possible, and CS courses should be as infrequent and as short as possible. The literature reviewed in this article clearly indicates that a short course of CS of 1 week, in the absence of specific contraindications, is unlikely to be harmful (psychotic or prepsychotic episodes possibly excepted).

[What are the cardiovascular complications of the analgesics and glucocorticoids?]

When prescribing a non-steroidal anti-inflammatory treatment but also an analgesic or a glucocorticoid, the cardiovascular risk of the patient should be assessed. The analgesics have few cardiovascular side effects and the main complications observed are linked essentially to the vagal action of the opioids. Acetaminophen is considered by several scientific societies to be the first line analgesic treatment, particularly in case of cardiovascular risk but with caution since cardiovascular toxicity of acetaminophen cannot be totally excluded. An overdose of dextropropoxyphene can result in cardiotoxicity. On the other hand, the glucocorticoids need to be prescribed cautiously, at the lowest possible dose and for the shortest possible duration due to the non-negligible cardiovascular risk, hypertension, dyslipidemia, hypokaliemia.

The effect of local corticosteroid or ketorolac exposure on histologic and biomechanical properties of rabbit tendon and cartilage

Tendonitis, tenosynovitis, and the arthritides are clinical problems commonly encountered in daily orthopaedic practice. Systemic anti-inflammatories, physical therapy, and local corticosteroid injections all are used as nonoperative treatments of these conditions. Systemic anti-inflammatory agents and local corticosteroid agents, however, can be associated with adverse effects that render them intolerable to some patients. As a preliminary study assessing the feasibility of local injection of nonsteroidal anti-inflammatory medication, the histological and biomechanical effects of local exposure of rabbit cartilage and tendon to injectable steroidal (corticosteroid) and injectable nonsteroidal anti-inflammatory agents (ketorolac tromethamine, KT) were determined. Thirty rabbits underwent bilateral knee joint, patellar tendon, and Achilles tendon injections with either normal saline, corticosteroid, or KT. Mechanical and histologic evaluation of the tissues was performed at 6 and 15 weeks after injection. Gross tendon adhesions were observed in more corticosteroid-treated specimens than those exposed to normal saline or KT. Microscopic evaluation of tendons revealed no significant differences among the three groups. Mild cartilage degenerative changes were noted across all groups. Evidence of cartilage necrosis was noted for the corticosteroid-treated group only. Tendons exposed to corticosteroid or KT demonstrated increased load and energy to failure, but exhibited no difference in material stiffness or strain. The use of an injectable nonsteroidal anti-inflammatory agent may be safe and even pose less threat to local tissues after intra-articular and peri-tendinous administration.

[Systemic corticosteroid therapy: patients' adherence to dietary advice and relationship between food intake and corticosteroid-induced lipodystrophy]

PURPOSE

No data is available about: 1) the adherence of corticosteroid-treated patients to dietary advice provided by physicians; 2) the relationship between food intake and the corticosteroid-induced lipodystrophy (CIL).

METHODS

We conducted a cohort study in 2 French tertiary centers between June 2003 and May 2005 and enrolled all consecutive patients starting long-term systemic corticosteroid therapy. They received individual dietary advice from a qualified dietetician and were asked to record on a standardized questionnaire everything they ate during one week of the first and third months of treatment, including details of each meal. Each questionnaire was analysed by two qualified dieteticians for daily calorie, carbohydrate, fat, protein and sodium intake. Moreover, 3 investigators assessed the development of CIL from standardized patients' photographs. The relationship between food intake and CIL was investigated by a multiple logistic regression model.

RESULTS

Eighty-eight patients were included and 80 were monitored until at least month 3 (women: 76%, mean age: 59.1+/-18.7 years). Most patients (65%) had giant-cell arteritis or connective tissue disease. The mean initial dosage of prednisone was 54+/-17 mg/day and the mean M3 dosage was 31+/-15 mg/day. Most patients were adherent to dietary advice during the first 3 months of therapy except for protidic ration which was below expected value. Sodium restriction was more strictly followed by women than by men. Multivariate analysis showed independent relationship between CIL and higher calorie intake (>30 kcal/kg/day). No relationship was evidenced between carbohydrate, protein, fat or sodium intake and the risk of CIL.

CONCLUSION

During the first 3 months of therapy, corticosteroid-treated patients are adherent to dietary advice. A calorie-controlled alimentation could be beneficial to limit the risk of CIL.

Dermatitis de manos

Hand dermatitis is a common skin disease that often has a chronic and relapsing course. Several subtypes of hand dermatitis have been described. In this review, we describe the clinical characteristics of each form of hand eczema, laboratory tests helpful in the diagnosis, and treatment options for this condition.

Effects of glucocorticosteroids on the skin and eye

The dermatologic anachronistic adage, "If wet--dry it, if dry--wet it!" has bee perhaps justifiably replaced by "Call the dermatologist to prescribe a steroid!" To say this without knowledge of the contents of this article and more importantly, to accept such cliches, is a disservice to the patient and a litigious liability to the prescriber. Recognizing the risk/benefit ratio of the most commonly used anti-inflammatory agents is essential. All therapies are most effective when used for their specific diagnosis. This article attempts to provide an update on the geometrically progressing knowledge regarding the uses and misuses of GCSs for the eye and skin.

Therapeutic options in the treatment of psoriasis and atopic dermatitis

A variety of therapeutic options are available to treat psoriasis and atopic dermatitis (AD). Local agents typically are used to treat localized and milder forms of disease, whereas phototherapy and systemic agents are used for more generalized and severe disease. Various combinations and sequences of topical or systemic therapies, or both, have been utilized in the treatment of psoriasis and, less frequently, of AD. Conventional systemic therapies for psoriasis, such as corticosteroids, oral calcineurin inhibitors, antimetabolites, and retinoids, are limited by their propensity to cause serious side effects. More recently, a number of immunobiologic agents, such as monoclonal antibodies, recombinant cytokines, and fusion proteins, have been approved by the Food and Drug Administration or are undergoing development as systemic antipsoriatic treatments. In many of these categories, a number of exciting new therapies are in development that may augment the existing armamentarium available to clinicians for the treatment of inflammatory skin diseases.

Corticosteroids: options in the era of steroid-sparing therapy

Topical corticosteroids remain the most commonly used topical treatments for inflammatory dermatoses, including psoriasis and atopic dermatitis. Topical corticosteroids are available in a variety of vehicles-creams, ointments, lotions, gels, and, more recently, foam. The vehicle used can substantially affect the individual agent's clinical action, potency, and acceptability to the patient. Moreover, some vehicles are better suited for specific body areas. Selection of the appropriate product should be determined by area of usage, physician experience, cost, and patient preference, particularly regarding vehicle. Although topical corticosteroids are associated with several side effects, including skin atrophy, telangiectases, purpura, and striae formation, appropriate usage can minimize these occurrences. Judicious use includes short-term, appropriate application as initial monotherapy or in combination strategies with other therapeutic agents that ideally possess complementing mechanisms of action. Examples include pulsing with high-potency topical corticosteroids and combination regimens with other topical agents such as topical calcineurin inhibitors, calcipotriene, or tazarotene. Appropriate education of patients and caregivers alike will facilitate the optimal use of these medications.

Fabrication, implantation, elution, and retrieval of a steroid-loaded polycaprolactone subretinal implant

A subretinal drug delivery system was developed to overcome the limitations of current treatments for retinal disease. A rod-shaped implant was made by embedding the corticosteroid triamcinolone acetonide within a biodegradable polycaprolactone polymer matrix. The implant was fabricated by homogeneously mixing the polymer and drug in solvent. The mixture was then dried, melted, and extruded, and the prepared solid form was drawn into a filament. The rods were mechanically sectioned to a length of 2 mm with a diameter of up to 320 microm. The rods were successfully implanted into the subretinal space of six rabbits. No complications were observed during the 4-week follow-up period. Initial observations of the implantation and elution characteristics revealed that polycaprolactone is well tolerated by the retinal tissue and that the implant can elute steroid for a period of at least 4 weeks without eliciting inflammatory response or complications. In vitro drug elution rates of different polymer to drug ratios and geometries into a balanced salt solution/bovine serum albumin (1%) solution showed an early rapid-release phase and late first-order phase. Histology and device retrieval after implantation revealed minimal encapsulation and good preservation of cellular morphology during the follow-up period and a more fibrous polymer microstructure of the implant.

Injectable corticosteroids in modern practice

Long-lasting, crystalline suspensions of injectable corticosteroids have been used to treat joint and soft-tissue disorders for many years; they decrease inflammation by reducing local infiltration of inflammatory cells and mediators. Depot formulations differ in their characteristics. Compounds with low solubility are thought to have the longest duration of action but may cause tissue atrophy when used in soft tissues. Intra-articular corticosteroids are commonly used to treat osteoarthritis and inflammatory arthritis: meta-analyses confirm their benefit in reducing pain and symptoms. Intra-articular corticosteroid injections have been shown to be safe and effective for repeated use (every 3 months) for up to 2 years, with no joint space narrowing detected. Fewer clinical trials are available for extra-articular uses for injectable corticosteroids, although there is evidence of efficacy in a variety of soft-tissue conditions. The accuracy of injections affects outcomes. Postinjection flare, facial flushing, and skin and fat atrophy are the most common side effects. Systemic complications of injectable corticosteroids are rare.

Therapeutic options for chronic hand dermatitis

Hand dermatitis is a common skin condition that often has a chronic and/or relapsing clinical course. Several clinical forms of hand dermatitis have been described, including contact (i.e., allergic and irritant), hyperkeratotic (i.e., psoriasiform or tylotic), frictional, nummular, atopic, pompholyx (i.e., dyshidrosis), and chronic vesicular hand dermatitis. In the present review, therapeutic options for these types of hand dermatitis are discussed in detail, focusing on treatments for recalcitrant hand dermatitis.

Recognizing and treating glucocorticoid-induced osteoporosis in patients with pulmonary diseases

Glucocorticoids are frequently used to treat patients with pulmonary diseases, but continuous long-term use of glucocorticoids may lead to significant bone loss and an increased risk of fragility fractures. Patients with certain lung diseases, regardless of pharmacotherapy-particularly COPD and cystic fibrosis-and patients waiting for lung transplantation are also at increased risk of osteoporosis. Fragility fractures, especially of the hip, will have substantial effects on the health and well-being of older patients. Vertebral collapse and kyphosis secondary to glucocorticoid-induced osteoporosis (GIO) may affect lung function. Identification of patients with osteopenia, osteoporosis, or fragility fractures related to osteoporosis is strongly recommended and should lead to appropriate treatment. Prevention of GIO in patients receiving continuous oral glucocorticoids is also recommended. In patients receiving either high-dose inhaled glucocorticoids or low- to medium-dose inhaled glucocorticoids with frequent courses of oral glucocorticoids, bone mineral density measurements should be performed to screen for osteopenia and osteoporosis. A bisphosphonate (risedronate or alendronate), calcium and vitamin D supplementation, and lifestyle modifications are recommended for the prevention and treatment of GIO.

Endocrine complications in pediatric patients with acute lymphoblastic leukemia

Endocrine complications of therapy for acute lymphoblastic leukemia (ALL) are common and are potentially debilitating both during and after therapy. Growth velocity slows during therapy for ALL, especially during the first year; however, children who do not receive cranial irradiation usually reach normal adult height. While growth hormone deficiency generally occurs in patients who have received 24Gy of cranial irradiation, it may also develop in those treated with lower doses (18Gy) of cranial radiation or with only high-dose methotrexate. Obesity commonly occurs during therapy and persists after completion of therapy. Osteopenia can occur early during therapy for ALL and can persist for many years. Adrenal insufficiency should be suspected in any child who has recently received glucocorticoid therapy, and stress doses of steroid should be administered in the event of metabolic stress. Screening of urine is useful for early detection of hyperglycemia during therapy with glucocorticoids and L-asparaginase. The syndrome of inappropriate secretion of anti-diuretic hormone is usually associated with vincristine therapy and may be aggravated by concurrent use of azole antifungals. Finally, patients who have received 18 or 24Gy of cranial irradiation may have clinical or subclinical deficiencies of thyroid hormones.

Corticosteroids in Crohn's disease

Crohn's disease is a lifelong illness characterized by chronic recurrent flares. The precise etiology of Crohn's disease is unknown. However, it appears to involve an enhanced systemic immune response and intensified local intestinal mucosal inflammatory activity, mediated through various inflammatory cells and an array of proinflammatory cytokines. Corticosteroids have been the mainstay of treatment of Crohn's disease. The controlled trials of the National Cooperative Crohn's Disease Study and the European Cooperative Crohn's Disease Study established that corticosteroids were effective for the induction of remission in Crohn's disease for the duration of the studies (6-17 wk). However, corticosteroids have not been shown to have an impact on the maintenance of long term remission in patients with Crohn's disease. In addition, they are associated with a high potential for dependence and serious toxic side effects. Alternative classes of medical therapy for Crohn's disease, including modified corticosteroids and a group of new biological therapies, have proven to be efficacious in the management of active and/or quiescent Crohn's disease.

Approach to corticosteroid-dependent and corticosteroid-refractory Crohn's disease

Corticosteroids are considered a drug of choice for the treatment of patients with moderately to severely active Crohn's disease (CD), an inflammatory bowel disease characterized by chronic recurrent flares of disease activity. However, among patients receiving corticosteroid therapy for induction of remission, 20% have corticosteroid-refractory disease and 36% of those with an initial response develop corticosteroid dependency within 1 year. Chronic corticosteroid exposure in patients who are corticosteroid dependent increases the risk for serious drug-related adverse effects. Withdrawal or reduction of corticosteroid therapy without exacerbation of symptoms is therefore recognized as an important goal of treatment. Therapies that have been shown to facilitate "steroid sparing' include the immunomodulators azathioprine/6-mercaptopurine and methotrexate and the antitumor necrosis factor-alpha monoclonal antibody infliximab. In corticosteroid-dependent patients, budesonide may be substituted for conventional corticosteroid therapy without loss of response and with less risk for toxicity, but its long-term efficacy requires further evaluation. A preliminary controlled study suggests that the investigational anti-TNF monoclonal antibody CDP-571 may also be clinically beneficial as a corticosteroid-sparing agent. This review summarizes the clinical evidence that supports consideration of these agents as alternatives in patients with CD who are dependent on, refractory to, or intolerant of conventional corticosteroid therapy.

Osteoporosis prevention in myasthenia gravis: a reminder

OBJECTIVES

Consensus guidelines for bone management of patients taking corticosteroids suggest two main interventions: Dual energy X-ray absorptiometry (DEXA) scanning in those taking prednisolone > or =7.5 mg daily for > or =6 months (repeated every 1-3 years as indicated). Bisphosphonate therapy for those taking prednisolone > or =15 mg daily for > or =6 months regardless of DEXA result, and also for patients with known or high risk of developing osteoporosis (including those aged >65 years).

MATERIAL AND METHODS

We audited adherence to these guidelines in all adults with myasthenia gravis (MG) attending our neurology service.

RESULTS

Of 80 patients with MG (47 male, mean age 63.3 years), 34 (43%) had received corticosteroids for > or =6 months. Eighteen were taking prednisolone > or =7.5 mg daily (mean dose 16.6 mg) yet only 4 of these (22%) had undergone DEXA scanning. Of the 13 patients meeting the guideline criteria to receive bisphosphonate therapy, this was prescribed to only 7 (54%). Two others were prescribed vitamin D, 2 a calcium supplement and 2 were receiving no prophylaxis.

CONCLUSION

In these MG patients the guidelines were followed in only a minority. Neurologists need greater awareness of the bone health consequences of prescribing long-term corticosteroids.

Update on systemic glucocorticosteroids in dermatology

Although dermatology now has the most extensive group of systemic medications available for the treatment of skin diseases at any time, GCSs remain the most important agents for managing inflammatory disorders. It is important that the dermatologist have a broad knowledge of guidelines for clinical use, pharmacology, and adverse effects of these drugs. Acute and chronic side reactions should be well recognized. An understanding of the HPA axis and reasons for administering GCSs in different ways is of great value. A good medical history should be taken on any patient treated with GCSs, including knowledge of conditions that would make GCSs inadvisable and other concomitant systemic medications that might produce drug interactions. During the course of therapy, physical examination should include all systems pertinent to side effects caused by these agents, including frequent evaluations of weight and blood pressure. Blood chemistries should be performed on a regular basis, including glucose, electrolytes, and serum lipids. Osteoporosis is one of the most significant adverse affects to be evaluated, with bone mineral density studies recommended on an annual basis for persons continuing on GCS therapy. If hip or other joint pain develops, MR imaging is the most specific and sensitive radiologic examination for evaluating the possibility of osteonecrosis. An ophthalmology examination should be performed every 6 to 12 months to detect early cataract or glaucoma development. Any early signs of infection should be evaluated by appropriate smears, wet preparations, and cultures. Many other studies, including gastrointestinal and pulmonary examinations, may be dictated by specific acute situations. It is important to begin early prevention of the bone loss that occurs with GCS-induced osteoporosis. The 1996 guidelines of the American College of Rheumatology, including adequate calcium and vitamin D intake, should be followed. Hormonal replacement, a bisphosphonate, calcitonin, or a thiazide diuretic may be indicated. Restriction of sodium in the diet is important, as well as adequate potassium intake. The diet should be low in saturated fat and calories and should be high in vegetable protein. Because osteoporosis is so prevalent with GCSs, keeping the patient as active as possible with mild-to-moderate exercise is important. Whenever possible, exposure to persons with infectious processes should be avoided, and proper treatment should be instituted at the initial signs of systemic or cutaneous infection. Oral doses of GCSs are best taken with food to prevent gastrointestinal irritation, and agents for gastric acidity occasionally may be indicated. Significant trauma should be prevented, as should severe exposure to the sun. Many situations may call for consultation with other medical or surgical subspecialists. The patient must be aware of the importance of regular physician evaluations and reporting of any adverse effects while on long-term GCSs. A good relationship and understanding between the patient and physician are vital in minimizing potential problems from these agents. If the dermatologist maintains the proper guidelines of care, patients on GCSs have the highest benefits and lowest risks possible.

Nutrition and ulcerative colitis

The role of diet in the aetiology and pathogenesis of ulcerative colitis (UC) remains uncertain. Impaired utilization by colonocytes of butyrate, a product of bacterial fermentation of dietary carbohydrates escaping digestion, may be important. Sulphur-fermenting bacteria may be involved in this impaired utilization. Oxidative stress probably mediates tissue injury but is probably not of causative importance. Patients with UC are prone to malnutrition and its detrimental effects. However, there is no role for total parenteral nutrition and bowel rest as primary therapy for UC. The maintenance of adequate nutrition is very important, particularly in the peri-operative patient. In the absence of massive bleeding, perforation, toxic megacolon or obstruction, enteral rather than parenteral nutrition should be the mode of choice. Nutrients may be beneficial as adjuvant therapy. Butyrate enemas have improved patients with otherwise recalcitrant distal colitis in small studies. Non-cellulose fibre supplements are of benefit in rats with experimental colitis. Eicosapentaenoic acid in fish oil has a steroid-sparing effect which, although modest, is important, particularly in terms of reducing the risk of osteoporosis, but it seems to have no role in the patient with inactive disease. gamma-Linolenic acid and anti-oxidants also are showing promise. Nutrients may also modify the increased risk of colorectal carcinoma. Oxidative stress can damage tissue DNA but there are no data published at present on possible protection from oral anti-oxidants. Butyrate protects against experimental carcinogenesis in rats with experimental colitis. Folate supplementation is weakly associated with decreased incidence of cancer in UC patients when assessed retrospectively. Vigilance should be maintained for increased micronutrient requirements and supplements given as appropriate. Calcium and low-dose vitamin D should be given to patients on long-term steroids and folate to those on sulphasalazine.