Corticosteroids are drugs which are widely used in treating multiple dermatological conditions. Dermatologists must be aware of different side effects of steroids to be able to detect and manage these adverse reactions.
One of the side effects of corticosteroids is the immunosuppressive effect.
Mechanism of immunosuppression?
Corticosteroids suppress the cell- mediated immunity. They act by inhibiting genes that code for the cytokines Interleukin 1 (IL-1), IL-2, IL-3, IL-4, IL-5, IL-6, IL-8, and TNF-alpha.
Corticosteroids suppress also humoral immunity. B cell counts may be decreased and immunoglobulin production may be inhibited.
Is it possible to early detect immunosuppression clinically?
Upon immunosuppression, the risk of infections increases, the patients becomes particularly susceptible to invasive fungal and viral infections, Unfortunately, corticosteroids mostly make it difficult to early detect infections because of inhibtion of inflammtion, fever and cytokine release. Fully expressed signs and symptoms may not be evident.
Risk factors of immunosuppression in patients on corticosteroids?
Old age.
Taking another additional immunosuppressive drugs or biologics.
Long term use of corticosteroids.
High dose (prednisolone >15 mg/day) increases the susceptibility to infections such as pneumonia and tuberculosis.
How to avoid immunosuppression complications in patients taking corticosteroids?
Alternate morning therapy and doses equivalent to <10 mg/day of prednisone reduce the chance of opportunistic infection.
A tuberculosis history should be taken and, if negative or uncertain, a tuberculin skin test or interferon-γ release assay performed prior to beginning therapy.
A chest radiograph should be obtained for patients with a positive tuberculin reaction (≥5 mm of induration in individuals receiving the equivalent of ≥15 mg/day of prednisone for a month or more) or interferon-γ release assay, a history of tuberculosis, or other risk factors (e.g. pre-existing immunosuppression).
Trimethoprim–sulfamethoxazole (TMP-SMX; e.g. one double strength tablet three times weekly or daily) may be given as a prophylaxis for patients with increased risk of having Pneumocystis jiroveci (carinii) pneumonia. Susceptible individuals include
Patients receiving glucocorticoid therapy at a dose equivalent to ≥20 mg/day of prednisone for longer than one month.
Patients with systemic inflammatory disorders such as granulomatosis with polyangiitis (Wegener granulomatosis) or SLE who are on additional immunosuppressive drugs or have pulmonary affection or lymphopenia.
HIV-positive individuals with CD4+ counts >200/mm3 who are receiving systemic glucocorticoid therapy.
Live virus vaccines should not be given to children or adults (if treated for ≥2 weeks) during or within a month after discontinuing glucocorticoid therapy at a dose equivalent to ≥20 mg/day of prednisone or ≥2 mg/kg/day in children weighing <10 kg.