July 2000
SAN FRANCISCO - Some of the key issues that clinicians encounter when prescribing systemic steroid therapy for children with dermatological conditions include parental concerns, increased risk of infection and vaccination schedules.
Common uses for glucocorticoids in pediatric dermatology include hemangiomas, contact dermatitis, lichen planus, Sweet's syndrome, vasculitis, rheumatologic diseases and various blistering disorders.
There are only a few absolute contraindications to steroid therapy, including invasive or systemic fungal infections, herpes simplex keratitis and known hypersensitivity to steroids. "However, there are a number of relative contraindications," said Amy Jo Nopper, MD,section of dermatology at Children's Mercy Hospital, Kansas City. "These include hypertension, diabetes, history of tuberculosis, cataracts, glaucoma, depression and psychosis. You also want to consider the effects of other medications on the activity of glucocorticoids, and vice versa."
Prednisone is the most common glucocorticoid used in pediatric dermatology. "Clinicians should keep in mind that the hepatic enzyme 11-b hydroxydehydrogenase is required to convert both cortisone and prednisone to their active forms of hydrocortisone and prednisolone," Nopper said here at the 58th Annual Meeting of the American Academy of Dermatology. "So when you have a patient that has severe hepatic disease, it may be beneficial to use prednisolone in place of prednisone."
| Common Uses for Glucocorticoids in Pediatric Dermatology |
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Parental concerns can be one of the biggest obstacles for clinicians when prescribing steroid therapy. "We know that we can expect weight gain, central obesity, moon facies, hair loss, hypertrichosis, striae, acne and distal wasting," she said. "We should remember to advise parents so that they are not shocked at the transformation of the children as we are treating them."
Systemic steroids also affect children's behavior. "Euphoria and depression are probably the most common symptoms," she said. "Side effects that we are likely to see include mild personality changes, depression, anxiety, withdrawn behavior and trouble sleeping. Overall, I think that these effects are the worst during the first few weeks of therapy and tend to normalize over the next several weeks."
A common parental concern is over the effects of steroid therapy on their child's growth. "Glucocorticoids tend to decrease the quantity of growth hormone as well as tissue sensitivity to growth hormone," she said. "The degree of growth suppression depends a lot upon the dose of the steroid as well as the underlying disease. However, catch-up growth has been seen in many patients on moderate steroid therapy."
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With the widespread use of day care and preschools, children are at increased risk of infections. "It is difficult to answer what is the exact risk of infection in these patients," she said. "It really depends on the dose of the steroid, the duration of treatment and underlying disease being treated."
Varicella is one of the most important infections that clinicians should consider in children on long-term systemic steroid therapy. "If you are going to be treating a child with long-term steroids, you should consider checking varicella zoster titers if there is a negative history," she said. "You also may want to consider checking this in household members with a negative history of varicella. In patients that you can postpone starting steroids on for at least one month, you should consider giving varicella vaccine (Varivax, Merck) to the patient and family members who are susceptible."
Administration of vaccines is another important issue in younger children being treated with systemic steroids. "You want to avoid live vaccines in patients taking steroids," she said. "These vaccines include measles-mumps-rubella (M-M-R II, Merck), oral poliovirus (Orimune, Wyeth Lederle) and varicella. Patients should be off of steroid therapy for at least one month before giving them live vaccines."
For more information:
- Nopper AJ. The pearls and perils of systemic steroids in pediatric dermatology. Presented at the 58th Annual Meeting of the American Academy of Dermatology. March 10-15, 2000. San Francisco.
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