Avoid Steroids as a First Line Therapy 避免使用类固醇作为一线疗法

A 40-year-old woman presented with a two-month history of worsening rashes on her chest, arms and legs. Twenty months before presentation she had received a diagnosis of eczema after the development of rash. Her skin rashes had been minimised since the initiation of treatment with topical steroids. She reported Betamethasone Valerate BP 0.025% application twice daily, reduced to once daily in the recent one week.

She underwent skin patch test and laboratory testing one month before presentation, including complete blood count, comprehensive metabolic panel, measurement of erythrocyte sedimentation rate and C-reactive protein level, and urinalysis. Test results were within normal range.

She also reported childhood asthma which had been in clinical remission since initiation of daily treatment with fluticasone inhaler at time of diagnosis, pump it as necessary currently. She does not smoke but drinks alcohol on social occasions.

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Physical examination reveal diffused small bumps distributed on her arms, chest, legs, hands and feet (Fig.1A, Fig.2A ). The patient’s eczema acute flare suggest steroids withdrawal syndrome. We advise her cease the steroid cream, the regimen of herbal medicine daily was started.

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She ultimately discontinued the Betamethasone. Four weeks after herbal medicine, new rashes were observed, intensive itch erythematous papules spread to her face, steroids withdrawal syndrome worsen. In a follow-up discussion with the patient, she took OTC antihistamines to manage the itch. In addition to continuing herbal medicine, the patient was treated with herbal cream for steroids withdrawal syndrome and eczematous itch.

The patient’s steroids withdrawal syndrome subsequently improved at month three, and no further flare occurred thereafter, herbal medication continued. The 6th month’s examination revealed her eczema full clearance. Watch treatment process video at https://www.youtube.com/watch?v=QTTVrIZdfrk

What exactly is a steroid?

Corticosteroids, often know as steroids, are anti-inflammatory medicines used to treat arange of conditions. Steroids mimic natural hormones produced in the body, including glucocorticoids (such as cortisol) and mineralocorticoids (such as aldosterone).  Topical steroids vary in structure depending the type of synthetic hormone incorporated, whether alone or combined with other adrenal cortex hormones.

Topical steroids can reduce inflammation (redness and swelling), suppress the immune system, and narrow the blood vessels in the skin. Their main purpose is to reduce skin inflammation and irritation.

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Hydrocortisone is a corticosteroid available in over-the-counter (OTC) medicines that was recommended to relieve itching associated with mosquito bites, minor skin irritations, inflammation, and rashes. However, patients are likely to be addicted after long-term treatment.  This paradoxical phenomenon has so far been underestimated, and improvement following the temporary rebound flare after discontinuation of corticosteroid therapy has been entirely ignored.

Prevalence of atopic diseases and the use of topical corticosteroids. Is there any connection?

The introduction of hydrocortisone to the nonprescription market in 1979 was a revolutionary move by the FDA [1-4]. The prevalence of atopic dermatitis has plateaued in many high-­income countries, it continues to increase in low­-income and middle-­income countries over the last 40 years [5-7].

The prevalence of atopic diseases (atopic dermatitis, bronchial asthma, allergic rhinitis) has considerably increased for the last 40 years. This tendency has coincided with the beginning of the epoch of the use of the topical corticosteroids, which have a potent immunomodulation action.
— AN Pampura, MD, Medical Hypotheses, 2005;64(3):575-8. https://doi.org/10.1016/j.mehy.2003.12.059

Reference:

  1. Lawrence M. Solomon. Over-the-counter hydrocortisone. Journal of the American Academy of Dermatology. 1979. 1(6): 561-562
  2. Peyton E. Weary. Over-the-counter hydrocortisone: Boon or boon-doggle?Journal of the American Academy of Dermatology. 1979. 1(5): 454–455
  3. E. William Rosenberg. Hydrocortisone creams over-the-counter: Not a worry. Journal of the American Academy of Dermatology. 1979. 1(5) :455
  4. Recommendations regarding the safety and effectiveness of hydrocortisone. Advisory panel review of OTC topical analgesic, antirheumatic, otic, burn, and sunburn protection and treatment drug products. December 4, 1979. FDA.
  5. Odhiambo JA, Williams HC, Clayton TO, Robertson CF, Asher MI. Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three. J Allergy Clin Immunol 2009; 124: 1251–58.
  6. Stefanovic N, Flohr C, Irvine AD. The exposome in atopic dermatitis. Allergy 2020; 75: 63–74.
  7. Sinéad M Langan,Alan D Irvine,Stephan Weidinger. Atopic Dermatitis. The Lancet. 2020; 396 (10247) :345-360