[Are Steroids Fearful Drugs?]

For the last decade in Japan, certain atopic dermatitis(AD) patients call steroids as to be "fearful drug", or even "demoniac drug" and tend to avoid using them.

I intend to consider why they think so in this article.

First I ask you;
If a drug make a disease look like completely cured and the disease violently gets back when the drug is stopped,
should we say the drug is "fearful"?

Since drugs in modern medicine are to suppress symptoms, i.e. not to cure diseases, symptoms naturally come back if the disease has not cured when the drug is stopped.
Imagine antifebriles you take while you had a cold; your fever gets back in some several hours after medication.

I feel steroids are drugs that tend to cause this "get back" strongly.

I said "I feel", which means the fact has not solved.

Generally, doctors and researchers are interested in effects/adverse effects of a drug when they use it, but not when they have finished using it.
Because they finished as they think the patient needs no more medication. They have nothing to do with the patient now.

Nevertheless, dermatologists cannot be ignorant about the rebound dermatitis when steroids(topical or oral) are suddenly stopped in severe eczematous patients.
That means such incidence is not rare enough for dermatologist to encounter.

But generally dermatologists think that rebound dermatitis of steroids occur in cese of inappropriate sudden stop of medication. They think proper reducing of steroids' dose and strongness as patients recovering is not dangerous.
"Get back" tendency of steroids did not exist in my medical and dermatological training provisions as well.

But I think dermatologists may be more ignorant of "get back" than patients.

Doctors see patients only when they come to their office, that is, only in several points of their long clinical course.
Doctors know nothing about patients who have left their office.

On the other hand, although patients know about only one case of themselves, they can observe all of their successional course, including pre- mid- and post-medication.

What happen after AD patients stop applying steroids, worsening or not worsening?

Parhaps dermatologists aren't so knowledgeable as they think themselves to be about that.
I think we dermatologist should be more modest to study from patients' experiences.

I was one of such ignorant dermatologists.

But I had some relative incidences concerning steroids in my dermatologic office, which made me wonder "Something is wrong. Why these patients do not cure?"

I prescribed topical steroids to eczematous patients as usual with warning not to continue applying when symptoms had vanished.

On the next visit, their skin had become quite clean.
Some of them brought back a little more steroids to satisfy themselves.

Most cases ended like that, but some came back with strangely aggravated symptoms.

I adviced them to continue medication, but things did not go well since then.

They seemed to end up eternal steroids use or good-bye to me.

I could persuade myself for the time being that they did not cure because thier allergen had not found.
But then, why their skin got so well for a time?
Why they wouldn't refuse to keep up using steroids which was not so effective now?

At another time, I met patients who stick to continuing steroids' application.

Although their symptoms seemed to have gone already and they should stop medication objectively, they resisted heatedly when I said I would weaken or stop their steroids.

Against my eager advice, they were very stubborn not to accept the fact that steroids should not be used coutinuously, and insisted "This drug fits for me. I need this by all means!"

Not only me but other dermatologists had similar experiences.
In many hospitals, there often were a few popular patients among us colleague dermotologists who always require dermovate(strongest topical steroids) and would never accept any alternative.

At that time I searched the reason of their tenacity in the shortness of precaution about adverse effects or the strong impact of steroids' effectiveness.

But their might be another reason.

If their symptoms were gone within the effect of steroids(when they came to see us dermatologists) and get back with the end of the effect, and only the steroids could suppress the symptoms again......
Then the steroids would be essential for them.
Is it a desperate vicious cycle like narcotic medication?

This vicious cycle may lead to so called addition to steroids.
In Japan, some dermatologists assert the existence of addiction (or dependence) into steroids, but most ones don't agree.

You Use Steroids(A) --> Symptoms Cleared --> Stop Steroids -
-> Still Cleared (B)
-> A Little Get Back but Soon Recovered(C)
-> Severe Get Back (D)

In above figure, B & C are good course.
Everybody anticipate those conclusions.

However, D might happen.
In those cases, you have to come back to A, and by repeating these A to D process, vicious cycles would be build.

There is one more worsening fact.
It is steroids' characteristic of tachypylaxis.

If this factor was added, the effectiveness of steroids would be diminish as long as you use them, concluding more strong steroids might be needed.

Incidentally, tachypylaxis occur in continual application, so some rest interval recover the effectiveness again.

This point leads to another ironic pitfall.

Suppose an AD patient continues steroids' application for a long time and at last steroids come to ineffective for his/her skin because of tachyphylaxis.
He/she gives up steroids and trys to go without steroids in the future.
But then rebound dermatitis comes and torments him/her.
He/she endures and endures and finally his/her willpower runs out.
Unwillingly, he/she desides to ask a dermatologist for help again.
He/she will be prescribed steroids and apply.
At that time, steroids' effectiveness will be exellent again since certain rest interval of application had taken.

The second time effectiveness is due to just enough rest time, not the ability or special steroids' power of the dermatologist.

Steroids have outstanding strong effect.
They improve symptoms much more surely and instantly than another drugs.

Though I have discussed nothing but negative aspects,
if the endpoints are B or C, steroids are sure to be the very good therapeutical option for AD, and AD patients actually feel "I was saved by steroids".

Then, what decides patients' destination to B/C or D?
How is the ratio?

Still unknown.

Since situation D is not generally admitted, no research has been conducted.
Even if such researchs are planned in the future, intentional or unintentional bias of papulation will easyly fluctuate the results.

AD patients live in almost lifetime long disease progress.
These unfavolable developments actually turn up after quite a long time of steroids' application, that is, see, 3, 5, 10 or 20 years.

It's no doubt that the patients' greatest concerns are whether their destinations are B/C or D.
If B/C, they will choose to use steroids as a matter of course, and if D, they won't to use them.

We don't know the most important thing yet.

The Japanese Dermatological Association(JDA) asserts;

"Steroids are the first choice of AD therapy."
"AD patients don't need to fear using steroids if they use them properly under JDA's guidance."

Though I'm a dermatologist and one of the members of JDA, I still feel that "Steroids are feaful".

Because steroids are drugs whose characteristic may cause the cycle like

1) Once you use symptoms gone,
2) Then when you stop decent get back come
3) Makes you keep using up and impossible to stop.

I don't intend to deny steroids or benefits of steroids many AD patients would have gained.

I just think that dermatologists should make it clear that there may be certain risk not only in "avoiding steroids" or "stopping steroids", but also in "using steroids".

And in present situation nobody knows which is better, I think the decision should be entrusted to patients.
Dermatologists should not force them to obey their policy but be ready to correspond to both cases.

2004.6.(translated in 2007.7)@

* related article:
Natural Limit of Topical Steroids Therapy

Written about my experience I was astonished by the "get back" of skin symptoms after stopping steroids.
Please read it as well if you like.

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