Systemic Corticosteroids in Dermatology
On this page
Direct answer
Systemic corticosteroids in dermatology are used for severe, widespread or rapidly progressive inflammatory disease, such as pemphigus, bullous pemphigoid, dermatomyositis and drug reactions like DRESS. Prednisolone is the usual oral agent, with higher doses reserved for pemphigus. Their hazards include HPA axis suppression, infection, osteoporosis, hyperglycaemia and hypertension, so they are tapered rather than stopped abruptly.
What you must remember
- Pemphigus vulgaris: prednisolone at about 1 mg per kg per day is a common starting dose, often combined with a steroid-sparing agent.
- Bullous pemphigoid: systemic steroids are used for extensive or severe disease, while potent topical steroids are preferred for localised disease.
- Dermatomyositis: systemic steroids are first-line, with steroid-sparing drugs added for chronic disease.
- DRESS: systemic steroids are the mainstay, given together with stopping the offending drug.
- HPA suppression: supraphysiological use beyond about three weeks can suppress the axis, risking adrenal crisis if stopped abruptly.
- Bone protection: calcium, vitamin D and bisphosphonates are considered for long courses.
- Infection screening: tuberculosis, hepatitis B and strongyloidiasis are excluded, since steroids can worsen them.
- Pneumocystis prophylaxis: considered with high-dose regimens, usually with cotrimoxazole.
A cautious course from start to stop
Systemic steroids act quickly, but harm accumulates with dose and duration. The sequence below keeps the benefit while limiting the cost, and it applies to most dermatology courses.
- Confirm and screen: confirm the diagnosis and exclude tuberculosis, hepatitis B and strongyloidiasis before starting, since steroids can worsen them.
- Start at the right dose: choose a dose matched to disease severity, for example about 1 mg per kg per day of prednisolone in pemphigus vulgaris.
- Add a steroid-sparing agent: azathioprine, mycophenolate or methotrexate reduces the cumulative steroid dose in chronic disease.
- Protect the patient: give calcium and vitamin D, check glucose and blood pressure, and consider Pneumocystis prophylaxis at high doses.
- Taper slowly: reduce the dose in steps guided by disease control, not by a fixed calendar.
- Watch for adrenal suppression: after long courses, use a slower taper and consider stress-dose cover during acute illness, since axis recovery can take months.
Patients on long-term steroids should carry a record of their treatment, so that surgery or acute illness triggers appropriate cover.
Where the exam tries to catch you
Steroid questions usually test the taper, the infection screen and the steroid-sparing rule.
- Trap: stopping prednisolone abruptly after a course longer than three weeks Correct: courses beyond about three weeks risk HPA suppression, so a taper is needed.
- Trap: relying on steroids alone for chronic pemphigus Correct: steroid-sparing agents reduce cumulative toxicity, which matters in a chronic disease.
- Trap: starting high-dose steroids without screening for tuberculosis or strongyloidiasis Correct: steroids can worsen both infections, so screening comes first.
Frequently asked questions
What is the usual starting dose of prednisolone in pemphigus vulgaris?
Prednisolone for pemphigus vulgaris is usually started at about 1 mg per kg per day, with higher doses for severe disease. The dose is adjusted according to disease control rather than a fixed schedule. A steroid-sparing agent is often added early to reduce the cumulative steroid dose.
When does systemic steroid use cause HPA axis suppression?
HPA axis suppression becomes a risk after supraphysiological systemic steroid use for more than about three weeks, and it can occur with shorter high-dose courses. Suppressed adrenal function can lead to adrenal crisis if steroids are stopped abruptly. A slow taper protects most patients from this risk.
Why is Pneumocystis prophylaxis given with systemic steroids?
Pneumocystis prophylaxis is considered with high-dose systemic steroids, especially when they are combined with other immunosuppressants. Cotrimoxazole is the usual agent. The decision depends on the dose, the duration of treatment and the underlying disease.
How should systemic steroids be tapered in dermatology?
Systemic steroids in dermatology are tapered gradually, guided by disease control and by the dose and length of treatment. A slow reduction in steps lowers the risk of relapse and adrenal suppression. Long courses need an extended taper, sometimes over several months.