Addressing Risks and Adverse Effects of Long-Term Topical Corticosteroid Use

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Long-Term Use of Topical Corticosteroids in Atopic Dermatitis (AD)

Background and Prevalence: In a large-scale survey involving approximately 1900 adults with AD and 270 caregivers of children with AD, it was found that 91% of patients have used topical corticosteroids (TCS) at some point during their treatment course. Among these, about 50% reported using TCS an average of 15 to 30 days per month, highlighting a significant reliance on this therapy for disease control.

Patterns of Use

• Patients reported application on an average of 4.7 distinct body areas, with usage extending to as much as 23% of total body surface area (BSA)
• The average reported duration of TCS use was around 15 years, suggesting prolonged and possibly continuous exposure in many cases

Patient Concerns and Adverse Effects

• Nearly 80% of patients expressed significant concern over the potential adverse effects associated with long-term TCS use
• Topical Steroid Withdrawal (TSW) Syndrome was reported or suspected by approximately 80% of patients, with notable symptoms including:
  • Rebound flares upon cessation
  • Burning sensations
  • Excessive skin peeling
  • Intense pruritus

These findings underscore a growing patient awareness and apprehension, likely amplified by discourse on social media and online platforms.

Systemic Absorption and Physiologic Impact

• High systemic absorption of TCS is possible, particularly when applied:
  • Over large BSA
  • To areas with thin skin, such as the eyelids, scrotum, and genitals
• Systemic absorption can lead to hypothalamic-pituitary-adrenal axis suppression, especially in patients using high-potency corticosteroids over extended durations
• In pediatric populations, there is evidence suggesting growth and developmental impacts from chronic topical steroid exposure

Skin Atrophy and Age-Related Risks

• Skin atrophy is a well-documented adverse effect of long-term corticosteroid use
• Elderly patients, who already experience age-related dermal thinning, are at a higher risk for steroid-induced skin atrophy
• Clinical emphasis should be placed on judicious TCS use in this population, with ongoing education and monitoring

Clinical Implications and Counseling

• Despite widespread use, there is a lack of robust, long-term studies delineating the full spectrum of effects related to chronic TCS use
• Clinicians must remain vigilant in counseling patients about:
  • Appropriate duration and application areas
  • Recognition of potential withdrawal symptoms
  • Strategies to mitigate adverse effects (eg, step-down approaches, steroid-sparing agents)

Conclusion: While TCS remain a cornerstone in the management of atopic dermatitis, their long-term use carries important risks that require careful balancing of benefits and harms. Increasing patient concern, emerging syndromes like TSW, and the potential for systemic effects underscore the need for personalized treatment plans, ongoing patient education, and the development of evidence-based guidelines for prolonged use.