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- Presentation
Reducing Steroid Side Effects: Osteoporosis, Mood, and Topical Steroid Risks
Description
The talk reviewed practical ways to reduce steroid side effects by using the lowest effective dose for the shortest duration, knowing dose and duration thresholds for specific risks, counseling patients, and documenting discussions. For bone health, glucocorticoids are a leading cause of secondary osteoporosis, with fracture risk rising even at low prednisone doses and bone loss occurring early; the speaker recommended calcium and vitamin D when appropriate, attention to modifiable risk factors, and referral to bone experts for patients on prolonged therapy, high doses, or with fracture history. Experts may use DEXA, vertebral fracture assessment, and FRAX to stratify risk and guide treatment, often with bisphosphonates first line when indicated. For mental health, steroids can trigger insomnia, anxiety, hypomania, depression, psychosis, delirium, memory issues, and suicidality, with risk influenced by dose, duration, age, sex, and psychiatric history, so patients should be warned and monitored even without prior mental health problems. The talk also covered topical steroids, emphasizing common local effects such as atrophy and telangiectasia, rare but possible systemic effects with heavy or prolonged use, and topical steroid withdrawal syndrome, which may present with redness, burning, itching, anxiety, and mood changes, especially on the face or groin. Management includes assessing use patterns, considering the differential, limiting potency and duration, avoiding sensitive areas, and switching to steroid-sparing topicals when possible.
View moreConclusions
- Glucocorticoid side effects are common, dose-related, and often begin early, so prevention should start as soon as steroids are prescribed.
- The safest general strategy is to use the lowest effective steroid dose for the shortest possible duration and to counsel patients about expected risks.
- Bone loss can occur even at low prednisone doses and within the first months of therapy, so bone health should be addressed for any patient expected to remain on steroids for about three months or longer.
- Preventing glucocorticoid-induced osteoporosis should include calcium, vitamin D, risk-factor assessment, and referral to endocrine or rheumatology when fracture risk is moderate or higher or other high-risk features are present.
- FRAX, DXA, and vertebral fracture assessment are useful tools for stratifying fracture risk, with FRAX used in adults 40 and older and Z-scores emphasized in younger adults.
- Bisphosphonates are generally first-line pharmacologic therapy for patients at sufficient fracture risk, but monitoring and individualized selection of therapy remain important.
- Steroid-related mood and cognitive effects can range from mild sleep or mood changes to severe depression, mania, delirium, psychosis, and suicidality, and these can occur even without prior psychiatric history.
- Higher steroid doses and longer duration increase neuropsychiatric risk, while age and sex influence the pattern of symptoms, so clinicians should proactively screen and warn patients.
- Topical steroids can also cause meaningful harm when used too long, too often, or at high potency, including skin atrophy and, less commonly, systemic effects.
- Topical steroid withdrawal syndrome is increasingly recognized, especially with prolonged facial or groin use, but diagnosis requires considering other causes and often trialing nonsteroidal alternatives.
- Overall, the presentation argues that dermatologists should actively prevent steroid toxicity by anticipating complications, documenting counseling, and using steroid-sparing approaches whenever possible.
- Humphrey, M.B., et al. 2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Rheumatol, 75: 2088-2102.
- Brookes et al. Clinical and Experimental Dermatology, 2023.
- Hajar et al. Journal of the American Academy of Dermatology, 2015.
- Hsu C, et al. Br J Dermatol. 2025 Dec 11:jaf518.