Glucocorticoids , local adverse effects

Local adverse effects are common in patients with asthma who use inhaled glucocorticoids, as suggested by a survey of the prevalence of throat and voice symptoms in patients with asthma using glucocorticoids by metered-dose pressurized aerosol (SEDA-20, 369 35). 

Topical administration to the nose The safety of nasal glucocorticoids in the treatment of allergic rhinitis has been reviewed (434,435). The local application of glucocorticoids for seasonal or perennial rhinitis often results in systemic adverse effects. The use of nasal sprays containing a glucocorticoid that has specific topical activity (such as beclomethasone dipropionate or flunisolide) seems to reduce the systemic adverse effects, but they can nevertheless occur, even to the extent of suppression of basal adrenal function in children (436). Local adverse effects include Candida infection, nasal stinging, epistaxis, throat irritation (437), and, exceptionally, anosmia (438). 

The local adverse effects of inhaled glucocorticoids have been studied in a prospective, cross-sectional, cohort study in 639 asthmatic children using beclomethasone (721 micrograms/day) or budesonide (835 micrograms/ day) for at least one month (28). The local adverse effects included cough (40%), thirst (22%), hoarseness (14%), dysphonia (11%), oral candidiasis (11%), perioral dermatitis (2.9%), and tongue hypertrophy (0.1%). A spacer doubled the incidence of coughing. 

The local adverse effects of topical glucocorticoids (1,2) are listed in Table 1. They include transient local... 

Table 1 Local adverse effects of topical glucocorticoids...

The local adverse effects of topical glucocorticoids (1,2) are listed in Table 1. They include transient local erythema, calcinosis cutis, cramps (due to injection of crystals into a vessel), amaurosis (a dubious report), depigmentation, skin atrophy, and skin necrosis (3,4). The systemic adverse effects of topical glucocorticoids (5-8), which are those to be expected from systemic use, are also listed in Table 1. 

Most knowledge of the adverse effects of glucocorticoids has been acquired in connection with their use as oral products. However, various other routes of administration have been developed, sometimes specifically in the hope of securing a local therapeutic effect while avoiding systemic adverse reactions. Although experience has shown that the latter cannot be eliminated in this way, they can be diminished in some cases. In other cases, new problems arise. Administration by inhalation is covered in the monograph on inhaled glucocorticoids. 

Local and systemic adverse effects of ophthalmic glucocorticoids occur in children more often, more severely, and more rapidly than in adults, for unknown reasons. It could be that children have relatively immature chamber angles, giving rise to a rapidly increasing intraocular pressure (432). 

The effects of intrathecal administration, both wanted and unwanted, are still much debated (448). The question as to whether oral glucocorticoid therapy should be preferred to intrathecal injections is raised by the harmful effects that have sometimes occurred after the latter, although some of these may have been caused by irritative substances in the injection fluid (SEDA-6, 331). The same local glucocorticoid concentrations can probably be attained with fewer problems with oral administration. Epidural injection of glucocorticoids seems to be safer than intrathecal injection, but injection of high doses can cause the same systemic adverse effects as seen with oral treatment. Facial flushing and erythema after lumbar... 

Intra-articular and periarticular administration Local injections of glucocorticoids into and around the joints can have a dramatic therapeutic effect, but the catabolic effect can have serious consequences, including adverse effects on joint structure (461) and on local tendons, subcutaneous atrophy, and possibly osteonecrosis. Provided the state of the joint is carefully inspected before any new injection is given, and the interval between the injections is not less than 4 weeks, the risk seems to be small enough to justify treatment in invalidating cases (SEDA-3, 307). 

Local and systemic adverse effects of ophthalmic glucocorticoids occur in children more often, more severely,... 

The main adverse effect of pimecrolimus is local skin irritation, with a stinging or burning sensation, which occurs in 30% of patients. Typically, children have less skin irritation than adults. Adverse effects such as local immunosuppression and an increased risk of local bacterial and viral infections (notably eczema herpeticum) are less common than with topical glucocorticoids (5). In addition, there is a lack of skin atrophy (6,7). However, topical corticosteroids have the advantage of better skin penetration than pimecrolimus and will therefore continue to be used for more heavily keratinized skin such as in psoriasis (8). 

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