tag:theconversation.com,2011:/au/topics/corticosteroid-4324/articlesCorticosteroid – The Conversation2023-06-20T02:22:42Ztag:theconversation.com,2011:article/2035752023-06-20T02:22:42Z2023-06-20T02:22:42ZCan I put cortisone on my face? The right advice on creams to fix irritated skin<figure><img src="https://images.theconversation.com/files/530540/original/file-20230607-17-118jjr.jpg?ixlib=rb-1.1.0&rect=49%2C32%2C5378%2C3607&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/skin-care-young-man-putting-face-1643342416">Shutterstock</a></span></figcaption></figure><p>Topical corticosteroids, also referred to as corticosteroids or cortisone, are the <a href="https://pubmed.ncbi.nlm.nih.gov/33719380/">go-to treatment</a> for many skin disorders including eczema, dermatitis and psoriasis. They can be found in <a href="https://www.ncbi.nlm.nih.gov/books/NBK532940/">various forms</a> such as creams, ointments, and solutions. </p>
<p>These medications <a href="https://ijdvl.com/topical-corticosteroids-in-dermatology/">work</a> by entering the skin cells and mimicking natural hormones, <a href="https://www.verywellhealth.com/how-topical-steroids-work-1068833#citation-1">blocking inflammation</a> and constricting blood vessels. Topical corticosteroids come in <a href="https://www1.racgp.org.au/ajgp/2021/september/selection-of-a-corticosteroid">different strengths</a>, from mild (such as 0.5% Hydrocortisone, available over the counter) to very potent prescription formulations. </p>
<p>But the way different people react to topical steroids can be unpredictable. While some people might get significant relief with short-term use, others could need continuous care.</p>
<p>So, how should you use cortisone creams and ointments? And why is there conflicting advice about their long-term use?</p>
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Read more:
<a href="https://theconversation.com/health-check-why-do-we-get-dry-skin-in-winter-60849">Health Check: why do we get dry skin in winter?</a>
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<h2>‘Use sparingly’</h2>
<p>Patients are currently recommended to use cortisone formulations “sparingly” or “thinly”. But this can increase the risk they won’t work effectively. Treatment failure can add to “<a href="https://pubmed.ncbi.nlm.nih.gov/34287768/">steroid phobia</a>” and stop people getting the medication they need. </p>
<p>Such warnings ignore the fact many patients are prescribed modest-strength topical steroids, which are <a href="https://doi.org/10.1111/j.1365-2133.2008.08479.x">safe and effective</a> when used properly. <a href="https://www.tandfonline.com/doi/full/10.1080/09546634.2019.1620502">Adverse effects</a>, such as when the formulations damage or irritate skin, are not typical. </p>
<p>From the patient’s perspective, the <a href="https://pubmed.ncbi.nlm.nih.gov/18294314/">current warnings</a> lump all steroids together regardless of their potential for side effects. Also, the advice tends to support false concerns: that topical and ingested (orally taken) corticosteroids carry the same dangers, which <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2796.2005.01467.x">they do not</a>.</p>
<h2>Mixed messages</h2>
<p>Should you use a weaker formulation for longer? Or hit the problem hard with a stronger concentration for less time?</p>
<p>At the moment, some treatment recommendations – such as for scalp <a href="https://pubmed.ncbi.nlm.nih.gov/31138038/">psoriasis</a> – say patients should use a high-dose cortisone formulation for four weeks and increase frequency of use if it’s not effective. If cortisone is extensively used, it is advised adults and children should be examined yearly for side effects.</p>
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<a href="https://images.theconversation.com/files/529006/original/file-20230530-23-2qp4o2.jpg?ixlib=rb-1.1.0&rect=46%2C46%2C5106%2C3305&q=45&auto=format&w=1000&fit=clip"><img alt="person rubs white skin cream on to hand" src="https://images.theconversation.com/files/529006/original/file-20230530-23-2qp4o2.jpg?ixlib=rb-1.1.0&rect=46%2C46%2C5106%2C3305&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/529006/original/file-20230530-23-2qp4o2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/529006/original/file-20230530-23-2qp4o2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/529006/original/file-20230530-23-2qp4o2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/529006/original/file-20230530-23-2qp4o2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/529006/original/file-20230530-23-2qp4o2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/529006/original/file-20230530-23-2qp4o2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Some conditions need long-term cortisone treatment – so breaks might be needed.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/applying-emollient-dry-flaky-skin-treatment-551219659">Shutterstock</a></span>
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<p>Skin atrophy (or deterioration) is the <a href="https://pubmed.ncbi.nlm.nih.gov/16384751/">most common side effect</a> of topical corticosteroids and manifests as tiny degenerative alterations within a few weeks. The patient’s age, body site, cortisone potency and the existence of any coverings, all have an impact on the extent of skin damage. </p>
<p>Reduced skin cell growth, decreased collagen development and stimulation of tiny vessels and capillaries in the skin are the <a href="https://pubmed.ncbi.nlm.nih.gov/25396122/">main features</a> of such skin atrophy. Thinner skin, more moisture, higher temperatures, and partial blockage make areas where skin folds on the body (for example, the armpits, between fingers, the groin) particularly vulnerable. These are also often the sites of skin irritation needing treatment. </p>
<h2>Skin thinning</h2>
<p>Topical steroids cause the skin to reabsorb a type of connective tissue building block, called <a href="https://www.histology.leeds.ac.uk/tissue_types/connective/connective_groundS.php#:%7E:text=The%20'ground%20substance'%20of%20extracellular,even%20larger%20molecules%20called%20proteoglycans.">mucopolysaccharide ground material</a>. Repeated use in the same spot on the body <a href="https://onlinelibrary.wiley.com/doi/book/10.1002/9780470750520">results in alterations</a> to the skin’s connective tissue and epidermal thinning. </p>
<p>That can result in lax, translucent, wrinkled skin as well as striae (stretch marks), fragility, hypo-pigmentation (fading) and the prominence of underlying veins. </p>
<p>More research is needed to help specialists choose the best corticosteroids for a given condition. High-potency cortisone formulations, long-term use and sun exposure have been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6910795/">implicated</a> in chronic fragile skin syndrome, which is increasingly common and features the symptoms outlined above.</p>
<p>However, if best <a href="https://www.nice.org.uk/guidance/cg153/chapter/5-Other-versions-of-this-guideline-full-guideline">practice guidelines</a> are followed, these side effects can be reduced by using lowering the potency of corticosteroids and stopping treatment when the patient has fully recovered. </p>
<p>Corticosteroids should only be used for a maximum of three months. For some conditions, such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5300730/">vitiligo</a>, they need to be used for longer periods, so regularly taking several weeks’ break is advised. </p>
<p>The good news is that once topical corticosteroids are stopped, short-term atrophy from treatment <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7779293/">can be reversed</a>, although skin normalisation may take months.</p>
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<a href="https://images.theconversation.com/files/530523/original/file-20230607-23-ca22fh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="cream on scratched up skin" src="https://images.theconversation.com/files/530523/original/file-20230607-23-ca22fh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/530523/original/file-20230607-23-ca22fh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/530523/original/file-20230607-23-ca22fh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/530523/original/file-20230607-23-ca22fh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/530523/original/file-20230607-23-ca22fh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/530523/original/file-20230607-23-ca22fh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/530523/original/file-20230607-23-ca22fh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Patients need reassurance and guidance on how much cortisone cream to use and for how long.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cortisone-cream-spread-on-irritated-skin-1658002459">Shutterstock</a></span>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/drugs-and-the-sun-your-daily-medications-could-put-you-at-greater-risk-of-sunburn-170559">Drugs and the sun – your daily medications could put you at greater risk of sunburn</a>
</strong>
</em>
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<h2>Can you use it safely on your face?</h2>
<p>Due to the substantial risk of steroid-induced skin deterioration, the guidelines recommend against using potent and very potent corticosteroids on the face, flexures (parts of the body that bend, such as elbows) or genitalia. So, mild to moderate-potency corticosteroids are the main treatment option. </p>
<p>Using strong cortisone creams or ointments on the face can lead to <a href="https://pubmed.ncbi.nlm.nih.gov/31138038/">steroid dependence</a>. Patients who are dependent on steroids and have acne, rosacea, perioral dermatitis or telangiectasia (widened blood vessels on the skin) continue to use the drug because they worry stopping the drug could worsen their condition. </p>
<p>Topical steroids on the face can cause symptoms sometimes referred to as “red face syndrome”, dermatitis rosaceaformis steroidica or <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885178/">steroid addiction</a>. And stopping <a href="https://pubmed.ncbi.nlm.nih.gov/21393945/">steroid use on the face</a> after an extended period can have considerable rebound effects including erythema (redness), burning and scaling.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-sodium-lauryl-sulfate-and-is-it-safe-to-use-125129">What is sodium lauryl sulfate and is it safe to use?</a>
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<h2>The bottom line</h2>
<p>When used correctly, cortisone creams, ointments and lotions can be safe and effective. </p>
<p>Clear instructions could include estimating dosage in “<a href="https://pubmed.ncbi.nlm.nih.gov/23097521/">fingertip units</a>”, with a chart showing the number of units needed for various body parts, such as <a href="https://patient.info/treatment-medication/steroids/fingertip-units-for-topical-steroids">one unit to treat skin on an adult’s hand</a> but seven units to treat skin on their back.</p>
<p>To avoid skin damage, corticosteroids should only be used on skin affected by a skin disease. Better education and information <a href="https://www.racgp.org.au/afp/2017/may/general-practitioners-knowledge-about-use-of-t-2">is needed</a> to reflect the minimal risks from topical corticosteroids that are low to moderate strength and how important it is to use enough medication to treat a condition. </p>
<p>Finally, treatment should be customised based on the person’s symptoms, the body parts affected and how long treatment might be required.</p><img src="https://counter.theconversation.com/content/203575/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yousuf Mohammed receives funding from U.S FDA grants. This article reflects the views of the author and
should not be construed to represent views or
policies.</span></em></p><p class="fine-print"><em><span>Khadeejeh AL-Smadi does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Patients and some doctors have an inflated sense of the risks of low-to-moderate strength cortisone cream and might not use enough to be effective.Yousuf Mohammed, Dermatology researcher, The University of QueenslandKhadeejeh AL-Smadi, PhD Candidate, Frazer Institute,, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1957002022-12-16T13:13:41Z2022-12-16T13:13:41ZRSV treatments for young children are lacking, but the record 2022 cold and flu season highlights the urgency for vaccines and other preventive strategies<figure><img src="https://images.theconversation.com/files/501170/original/file-20221214-15092-osjj0p.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C7951%2C5297&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Only one antiviral medication is approved by the FDA for RSV treatment, and it is administered through a nebulizer.
</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/asian-boy-using-inhaler-containing-medicine-to-stop-royalty-free-image/1227487354?phrase=RSV&adppopup=true">BonNontawat/iStock via Getty Images Plus</a></span></figcaption></figure><p>For many parents, respiratory syncytial virus – or RSV – which has been causing <a href="https://theconversation.com/rsv-a-pediatric-disease-expert-answers-5-questions-about-the-surging-outbreak-of-respiratory-syncytial-virus-193275">record numbers of hospitalizations of children</a> during the fall of 2022, may sound like a relatively new and unheard-of threat. But in fact, RSV is a <a href="https://www.cdc.gov/mmwr/volumes/71/wr/pdfs/mm7140a1-H.pdf">common respiratory virus</a> that circulates every fall and winter and is a common cause of lung infections in young children.</p>
<p>RSV can be difficult to distinguish from other respiratory infections since the symptoms are common to other illnesses – runny nose, sneezing, congestion, coughing, fever, decreased appetite and wheezing. In most cases, RSV is mild and will improve at home. However, in certain cases, it can cause severe illness and require hospital treatment. </p>
<p>RSV can cause severe infections and pneumonia in anyone, including <a href="https://www.cdc.gov/rsv/high-risk/older-adults.html">adults 65 years and older</a> and those with chronic lung or heart conditions or weakened immune systems. But it is most commonly severe in young children.</p>
<p>We are <a href="https://scholar.google.com/citations?user=Pu3L9HkAAAAJ&hl=en">an epidemiologist</a> and a <a href="https://www.bcm.edu/people-search/flor-munoz-rivas-27227">pediatric infectious disease physician</a> and have seen the effects of RSV on children firsthand. </p>
<p>Unfortunately, although RSV is a very common respiratory threat, treatments for it are relatively limited, and as yet, there is no vaccine against it. However, 2023 is likely to be a pivotal year for RSV prevention strategies and treatments.</p>
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<figcaption><span class="caption">How to keep your child safe from RSV.</span></figcaption>
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<h2>Treating children for RSV</h2>
<p>Current guidelines <a href="https://www.cdc.gov/rsv/about/symptoms.html">recommend supportive</a> care, which essentially means managing symptoms and trying to make children as comfortable as possible until they are well again. This includes offering plenty of fluids to avoid dehydration and using over-the-counter medications such as acetaminophen to reduce any fever. </p>
<p>Antibiotics are not useful for treating RSV since they only target bacterial infections and RSV is caused by a virus. But sometimes, children with RSV can also develop secondary bacterial infections in the lungs, in which case antibiotics may be prescribed. </p>
<p>There are a range of medications that have been tried on children with RSV, but for the most part, they’ve shown little benefit. For example, many studies have <a href="https://www.cochrane.org/CD001266/ARI_bronchodilators-for-bronchiolitis-for-infants-with-first-time-wheezing">trialed the use of inhalers</a> and <a href="https://doi.org/10.1001/archpedi.158.2.127">corticosteroid medications</a>, but results have shown that neither significantly reduces the severity of RSV. These medications are therefore not routinely recommended for children to treat severe RSV.</p>
<p>The only drug approved by the Food and Drug Administration to treat RSV is <a href="https://medlineplus.gov/druginfo/meds/a605018.html">ribavirin</a>, an antiviral medication. It is aerosolized using a special nebulizing machine and needs to be given in the hospital for periods of eight to 24 hours over three to five days. The drug works by trying to stop the virus from replicating in the respiratory tract. </p>
<p>The trials evaluating ribavirin <a href="https://doi.org/10.1002/14651858.CD000181.pub3">have been small</a>, which means we can’t really be certain of its benefits. Because ribavirin is very expensive and its benefits uncertain, the American Academy of Pediatrics <a href="https://doi.org/10.5863/1551-6776-23.5.372">no longer routinely recommends</a> it for treatment of RSV, except for specific cases in very high-risk patients.</p>
<p>Fortunately, most babies and young children with RSV do not require treatment and recover well with supportive care. But some can become very ill and need substantial care from their doctors, parents and family members. </p>
<p>While RSV can result in <a href="https://doi.org/10.1542/peds.2019-3611">serious disease for any child</a>, children in <a href="https://www.cdc.gov/rsv/clinical/index.html">high-risk groups</a> face more serious threats from RSV. These include babies less than 6 months old, premature infants, children under 2 years old with chronic lung disease or congenital heart disease, children with suppressed immune systems and children with neuromuscular disorders.</p>
<p>Children may require hospital care if they are having difficulty breathing, have a fever that does not go away after two days, or have lost energy and no longer eat, drink or urinate. This is primarily so they can be monitored and receive intravenous fluids to keep hydrated and ventilators to help with breathing. Approximately <a href="https://www.cdc.gov/rsv/clinical/index.html">1%-2% of babies less than 6 months old</a> with RSV will be hospitalized. </p>
<p>It’s important to know that children infected with RSV might take a turn for the worse before they get better. This is because, in addition to severe nasal congestion that interferes with their feeding, the inflammation in their airways and lungs may prevent them from breathing properly and keeping a normal oxygen level in their blood. These are the children who end up in emergency rooms and hospitals during the respiratory virus season.</p>
<h2>The future of RSV treatment is prevention</h2>
<p>Since effective treatments for severe RSV in children are so limited, the primary goal is to prevent the disease from happening in the first place. </p>
<p>One prevention strategy is to treat infants and children who are at high risk of severe disease before they get sick. This includes very preterm infants and those with heart and lung conditions. </p>
<p>A <a href="https://doi.org/10.1002/14651858.CD006602.pub4">monoclonal antibody called palivizumab</a> can be given as a series of shots and is usually reserved for use during the RSV season. But since RSV has been so variable throughout the COVID-19 pandemic, and in response to the early increase in RSV hospitalizations in children this year, the American Academy of Pediatrics recently <a href="https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/interim-guidance-for-use-of-palivizumab-prophylaxis-to-prevent-hospitalization/">updated its guidelines</a> to allow administration of palivizumab whenever RSV is in high circulation.</p>
<p>But to really get ahead of the RSV threat, we believe the health care field needs prevention strategies that can protect all children from the disease from birth.</p>
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<figcaption><span class="caption">RSV, flu and COVID-19 cases continue to fill U.S. hospitals.</span></figcaption>
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<h2>The promise of vaccines</h2>
<p>Despite more than five decades of research, there is still no RSV vaccine available for children. This is because developing a vaccine that really works has been tricky. RSV vaccines target the <a href="https://microbiologycommunity.nature.com/posts/53435-rsv-f-protein-an-attractive-target-for-therapeutic-intervention">F protein</a>, the part of the virus that it uses to infect cells, and this protein has different forms before and after infecting the cells. <a href="https://doi.org/10.1016/j.smim.2013.04.011">RSV vaccines are in development</a> for three groups, including infants 4 to 6 months old, adults 65 years and older, and pregnant people. </p>
<p>RSV vaccination during pregnancy produces RSV-specific antibodies in the mother that can then <a href="https://doi.org/10.1016/j.ijid.2021.06.015">cross the placenta</a> to protect the baby. These maternal antibodies generally offer protection for the first six months of a baby’s life. A recent clinical trial showed that RSV vaccination during pregnancy <a href="https://www.pfizer.com/news/press-release/press-release-detail/pfizer-announces-positive-top-line-data-phase-3-global">reduced the risk of RSV hospitalization by 82%</a> in infants less than 3 months old. These are very promising results.</p>
<p>Another viable option for the prevention of RSV for all young babies is the use of long-acting RSV-specific antibodies that can be given either at birth or prior to the RSV season. These could provide immunity to infants for several months while RSV is in circulation. A recent clinical trial showed that one of these products, nirsevimab, <a href="https://doi.org/10.1056/NEJMoa2110275">reduced the risk of RSV hospitalization by 62%</a> in children less than 1 year old. </p>
<h2>Looking ahead</h2>
<p>One positive outcome of fall 2022’s record RSV season is that it has raised public awareness of RSV and created renewed urgency around the need to find more effective preventive strategies and RSV treatments.</p>
<p>The success of these tools and strategies will largely depend on their acceptance and utilization by well-informed parents and providers. </p>
<p>Usually, parents become aware of RSV only after having experienced it in their own family. But pediatric providers know all too well from caring for their patients what RSV can do to young bodies. When parents and providers share these stories, it becomes a powerful testament to the need for preventive strategies to fight RSV.</p><img src="https://counter.theconversation.com/content/195700/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Annette Regan receives research funding from the National Institute of Allergy and Infectious Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the US Centers for Disease Control and Prevention.</span></em></p><p class="fine-print"><em><span>Flor Munoz-Rivas is a member of the Safety Monitoring Board for various vaccines under development with Pfizer, Moderna, Virometix, Meissa, Sanaria and the National Institutes of Health. She also has been part of Advisory Boards for topics related to respiratory pathogens and vaccines for Sanofi, Aztra-Zeneca, Moderna, Merck and GSK. She receives research funding from Pfizer, Gilead, the Centers for Disease Control and Prevention, and the National Institutes of Health. </span></em></p>While RSV can become severe for any child, it poses a particularly serious threat for the youngest babies and for high-risk children.Annette Regan, Assistant Professor of Epidemiology, University of San FranciscoFlor M. Munoz, Associate Professor of Pediatric Infectious Diseases, Baylor College of Medicine Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1455362020-09-04T02:48:39Z2020-09-04T02:48:39ZThe evidence is in. WHO says corticosteroids really do save lives of people critically ill with COVID-19<figure><img src="https://images.theconversation.com/files/356202/original/file-20200903-18-1b2w98x.jpg?ixlib=rb-1.1.0&rect=0%2C4%2C1000%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/dexamethasone-breakthrough-treatment-coronavirus-sarscov2-3d-1785888350">Shutterstock</a></span></figcaption></figure><p>Readily available drugs, which dampen the runaway inflammatory response in patients severely ill with COVID-19, save lives, according to evidence released this week.</p>
<p>An <a href="https://jamanetwork.com/journals/jama/fullarticle/2770279">analysis by the World Health Organisation</a> (WHO), which drew together results from several studies, confirms the benefit of this group of anti-inflammatory steroid drugs, known as corticosteroids.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1301271720087744512"}"></div></p>
<p>While <a href="https://theconversation.com/dexamethasone-the-cheap-old-and-boring-drug-thats-a-potential-coronavirus-treatment-140932">earlier studies</a> showed the apparent benefit of one of these drugs, dexamethasone, this latest evidence goes further.</p>
<p>It shows other cheap and readily available corticosteroid drugs, including hydrocortisone, could benefit patients at the life-threatening stages of coronavirus infection. </p>
<h2>Remind me again, what are corticosteroids?</h2>
<p><a href="https://www.nhsinform.scot/tests-and-treatments/medicines-and-medical-aids/types-of-medicine/corticosteroids">Corticosteroids</a> have been used for decades to treat a variety of inflammatory conditions. These include <a href="https://jamanetwork.com/journals/jama/fullarticle/2770275">severe forms of lung inflammation</a>, such as pneumonia, shock due to infection, and severe respiratory syndromes. They are also used to treat more common conditions, including asthma and eczema.</p>
<p>These medicines are on the <a href="https://www.who.int/topics/essential_medicines/en/">WHO list of essential medicines</a>, meaning they are widely available (usually at low cost).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-medicines-would-we-pack-for-a-trip-to-mars-47624">What medicines would we pack for a trip to Mars?</a>
</strong>
</em>
</p>
<hr>
<h2>What do we already know about corticosteroids for COVID-19?</h2>
<p>In June, early release of results from the <a href="https://www.recoverytrial.net/news/low-cost-dexamethasone-reduces-death-by-up-to-one-third-in-hospitalised-patients-with-severe-respiratory-complications-of-covid-19">RECOVERY trial</a> showed dexamethasone reduced the risk of death by up to a third in people hospitalised with COVID-19 who needed a ventilator to help them breathe.</p>
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<figcaption><span class="caption">Results of the dexamethasone trial were released early.</span></figcaption>
</figure>
<p>Despite the early release of the trial results, and limited details at the time, the findings were compelling and clinical practice changed. </p>
<p>Several other trials were stopped. All patients switched to receive active treatment with a corticosteroid.</p>
<p>The results of the RECOVERY trial have since been formally peer reviewed and <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2021436">published</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dexamethasone-the-cheap-old-and-boring-drug-thats-a-potential-coronavirus-treatment-140932">Dexamethasone: the cheap, old and boring drug that's a potential coronavirus treatment</a>
</strong>
</em>
</p>
<hr>
<h2>What does the latest evidence say?</h2>
<p>The WHO drew together results from <a href="https://jamanetwork.com/journals/jama/fullarticle/2770279">seven randomised clinical trials</a>, including data from 1,703 critically ill patients with COVID-19.</p>
<p>This is a powerful and compelling way to combine information and truly address the question of whether these medicines benefit people in hospital critically unwell with COVID-19.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/icu-ventilators-what-they-are-how-they-work-and-why-its-hard-to-make-more-135423">ICU ventilators: what they are, how they work and why it's hard to make more</a>
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<p>The study, which included patients from Australia and New Zealand, found almost 33% of people treated with corticosteroids died within 28 days of treatment. This was compared with 41% of patients who received supportive care (or placebo). Corticosteroid treatment helped patients whether or not they needed ventilation or oxygen. </p>
<p>Importantly, the analysis also concluded the benefits were not specific to one corticosteroid drug but were the same for dexamethasone and hydrocortisone. </p>
<p>Corticosteroids can also have an impact on the immune system. So the researchers looked at the risk of infection from other causes, for example bacterial pneumonia, and found it was not a major concern. </p>
<h2>What does this mean for patients?</h2>
<p>The weight of evidence has led <a href="https://www.who.int/publications/i/item/WHO-2019-nCoV-Corticosteroids-2020.1">WHO guidelines</a> this week to strongly recommend using corticosteroids to treat people with severe or critical COVID-19.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1301188713641398273"}"></div></p>
<p>This aligns with current <a href="https://covid19evidence.net.au/">Australian guidelines</a> for treating <a href="https://app.magicapp.org/#/guideline/L4Q5An/section/ny55yn">hospitalised patients</a> with COVID-19 needing oxygen support.</p>
<h2>Corticosteroids are not for everyone and are not a cure</h2>
<p>It is important to remember these findings only apply to using corticosteroids in critically ill people hospitalised with COVID-19. There is currently limited information to suggest these medicines are appropriate for people with mild COVID-19.</p>
<p>While corticosteroids help treat the body’s response to the coronavirus infection, they are not <a href="https://theconversation.com/in-the-fight-against-coronavirus-antivirals-are-as-important-as-a-vaccine-heres-where-the-science-is-up-to-133926">antiviral drugs</a>. They do not inhibit the virus itself, so they are not a cure.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/in-the-fight-against-coronavirus-antivirals-are-as-important-as-a-vaccine-heres-where-the-science-is-up-to-133926">In the fight against coronavirus, antivirals are as important as a vaccine. Here's where the science is up to</a>
</strong>
</em>
</p>
<hr>
<h2>A new way of doing research</h2>
<p>Usually, several clinical trials on a common theme are published over a series of years. Then a meta-analysis draws together their results, publishing these combined results much later.</p>
<p>But the amazing thing about this latest evidence is the meta-analysis included <a href="https://jamanetwork.com/journals/jama/fullarticle/2770277">data from</a> <a href="https://jamanetwork.com/journals/jama/fullarticle/2770276">clinical trials</a> <a href="https://jamanetwork.com/journals/jama/fullarticle/2770278">published</a> <em>at the same time</em>. This shows a degree of <a href="https://jamanetwork.com/journals/jama/fullarticle/2770275">co-operation and collaboration</a> between researchers to share data to urgently address important research questions that guide clinical care.</p>
<p>Evidence to guide the best treatments and management for people with COVID-19 continues to emerge. You can follow the evidence and how it’s applied in Australia <a href="https://covid19evidence.net.au/">here</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ivermectin-is-still-not-a-miracle-cure-for-covid-19-despite-what-you-may-have-read-144569">Ivermectin is still not a miracle cure for COVID-19, despite what you may have read</a>
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</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/145536/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew McLachlan receives research funding from the NHMRC and the Sydney Pharmacy School receives research scholarship funding from GSK for a PhD student under his supervision. Andrew has served as a paid consultant on Australian government committees related to medicines regulation and anti-doping. Andrew does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article.</span></em></p>Common and cheap drugs save lives of patients critically ill with COVID-19, a new analysis shows. But these corticosteroids are not a cure.Andrew McLachlan, Head of School and Dean of Pharmacy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1409322020-06-17T05:35:02Z2020-06-17T05:35:02ZDexamethasone: the cheap, old and boring drug that’s a potential coronavirus treatment<figure><img src="https://images.theconversation.com/files/342353/original/file-20200617-94060-1v1qsg3.jpg?ixlib=rb-1.1.0&rect=7%2C15%2C1014%2C751&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><span class="license">Author provided</span></span></figcaption></figure><p>First, we tried the antimalarial drug <a href="https://theconversation.com/could-taking-hydroxychloroquine-for-coronavirus-be-more-harmful-than-helpful-139309">hydroxychloroquine</a>. Then we tested the antiviral drug <a href="https://theconversation.com/is-remdesivir-a-miracle-drug-to-cure-coronavirus-dont-get-your-hopes-up-yet-137592">remdesivir</a>. But new UK research gives the strongest indication yet we may have found a useful treatment for COVID-19. </p>
<p>This time it’s an old anti-inflammatory drug, dexamethasone, which has been <a href="https://www.heraldscotland.com/news/18521350.cheap-old-boring-drug-save-thousands-lives-approved-treatment-covid-19/">described as</a> cheap, old and boring. </p>
<p>Preliminary results from a clinical trial <a href="http://www.ox.ac.uk/news/2020-06-16-dexamethasone-reduces-death-hospitalised-patients-severe-respiratory-complications">just released</a> indicate the drug seems to reduce your chance of dying from COVID-19 if you’re in hospital and need oxygen or a machine to help you breathe.</p>
<p>The results were significant enough for the UK to <a href="https://www.bbc.com/news/health-53061281">recommend its use</a> for severe COVID-19.</p>
<p>Before we roll it out in Australia, we need to balance the drug’s risks with its benefits after peer-review of the full trial data.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1272880206408290304"}"></div></p>
<h2>What is dexamethasone?</h2>
<p>Dexamethasone has been used since the late 1950s, so doctors are familiar with it. It’s also inexpensive, with a packet of 30 tablets <a href="http://www.pbs.gov.au/medicine/item/2507Y">costing around A$22</a> (for general patients) under Australia’s Pharmaceutical Benefits Scheme. </p>
<p>So if it does work for COVID-19, this cheap and boring drug, already available in Australia with a prescription, would be easy to add to current treatments.</p>
<p>Dexamethasone belongs to a class of drugs known as corticosteroids and is used to treat a range of conditions related to inflammation. These include severe allergies, some types of nausea and vomiting, arthritis, swelling of the brain and spinal cord, severe asthma, and for breathing difficulties in newborn babies. </p>
<p>And it’s dexamethasone’s application to those latter two respiratory conditions that prompted doctors to think it may also help patients severely affected by COVID-19.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/icu-ventilators-what-they-are-how-they-work-and-why-its-hard-to-make-more-135423">ICU ventilators: what they are, how they work and why it's hard to make more</a>
</strong>
</em>
</p>
<hr>
<h2>What did the trial find?</h2>
<p>The recently reported results come from the <a href="https://www.recoverytrial.net/">Randomised Evaluation of COVID-19 Therapy</a>, or RECOVERY, trial.</p>
<p>The researchers put patients into one of three groups: those needing ventilation (a machine that helps them breath); those who just needed oxygen therapy; and those who needed no treatment to help them breathe. </p>
<p>Patients in each of those groups were given dexamethasone (6mg once a day, either as a tablet or via intravenous injection), for ten days. A fourth group (a control group) was not given the drug.</p>
<p>Dexamethasone was most useful for the ventilated patients; deaths for this group dropped by about one-third with drug treatment. In contrast, deaths only dropped by one-fifth for those patients who were only receiving oxygen therapy. There was no benefit to patients who could breathe normally.</p>
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<figcaption><span class="caption">Results of the dexamethasone trial have just been released.</span></figcaption>
</figure>
<p>The researchers calculated that giving dexamethasone to eight ventilated patients would prevent one from dying, on average. And giving it to around 25 patients needing oxygen alone would prevent one death.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-fascinating-history-of-clinical-trials-139666">The fascinating history of clinical trials</a>
</strong>
</em>
</p>
<hr>
<h2>How might dexamethasone work for COVID-19?</h2>
<p>When a patient has severe COVID-19, their immune system ramps up to catch and control the virus in the lungs. </p>
<p>In doing this, their body produces more infection-fighting white blood cells. This results in inflammation and pressure on their lungs, making it very difficult for them to breath. </p>
<p>It’s therefore likely dexamethasone reduces this inflammation, and so reduces pressure on the lungs.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-does-coronavirus-kill-130864">How does coronavirus kill?</a>
</strong>
</em>
</p>
<hr>
<h2>What are the downsides?</h2>
<p>There are potential complications with using dexamethasone.</p>
<p>First, dexamethasone also suppresses the immune system when it reduces inflammation. So, it’s not usually recommended for people who are sick, or could be sick, from other infections. So doctors will need to make sure patients have no other infections before they are prescribed the drug. </p>
<p>If the results of this trial are correct though, the drug doesn’t appear to compromise the patient’s ability to fight COVID-19; it might just affect their ability to fight off other diseases.</p>
<p>Second, the drug is only useful for patients with difficulty breathing and needing some assistance either through ventilation in a hospital or from oxygen therapy. </p>
<p>There appears to be no benefit for patients who don’t need help breathing. So we shouldn’t be giving it to everyone who tests positive to the virus.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/in-the-fight-against-coronavirus-antivirals-are-as-important-as-a-vaccine-heres-where-the-science-is-up-to-133926">In the fight against coronavirus, antivirals are as important as a vaccine. Here's where the science is up to</a>
</strong>
</em>
</p>
<hr>
<p>Third, like all drugs, dexamethasone <a href="https://www.nps.org.au/medicine-finder/dexmethsone-tablets">has side effects</a> that need to be monitored. Serious, but rare ones include: severe stomach or intestinal pain, sudden changes with vision, fits, significant psychiatric or personality changes, severe dizziness, fainting, weakness and chest pain or irregular heartbeat, and swelling of the face, lips, mouth, tongue or throat, which may cause difficulty in swallowing or breathing.</p>
<h2>What happens next?</h2>
<p>The results of the clinical trial are preliminary. So we need to wait for the full study data and scientific peer-review before we can make a definitive decision as to whether dexamethasone treatment is a worthwhile, and safe, addition to COVID-19 therapy in Australia.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-if-the-vaccine-or-drugs-dont-save-us-plan-b-for-coronavirus-means-research-on-alternatives-is-urgently-needed-136833">What if the vaccine or drugs don't save us? Plan B for coronavirus means research on alternatives is urgently needed</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/140932/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Associate Professor Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is Fellow of the Royal Australian Chemical Institute and a member of the Australasian Pharmaceutical Science Association. Nial is also a director of the medicinal cannabis company Canngea Pty Ltd and a Standards Australia committee member for sunscreen agents.</span></em></p>Preliminary results indicate dexamethasone could help treat severely ill patients in hospital with COVID-19. But it’s early days yet.Nial Wheate, Associate Professor | Program Director, Undergraduate Pharmacy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/818932017-08-03T02:48:37Z2017-08-03T02:48:37ZWeekly Dose: methylprednisolone, a drug for treating inflammation but not rare kidney disease<figure><img src="https://images.theconversation.com/files/180649/original/file-20170802-11374-1dpcm62.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Methylprednisolone, the corticosteroid that's used to treat serious asthma attacks, works by reducing inflammation.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/518348707?size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Methylprednisolone is a prescription drug used to treat conditions involving inflammation, like asthma, arthritis, gout, tendinitis, transplant rejection, allergic reactions, and the skin conditions eczema and psoriasis.</p>
<p>It’s in the news because doctors have been trialling the drug to see if it helped treat a rare kidney condition called IgA nephropathy, also known as <a href="http://kidney.org.au/cms_uploads/docs/rrc-iga-nephropathy.pdf">Berger’s disease</a>.</p>
<p>A study <a href="http://dx.doi.org/10.1001/jama.2017.9362">published this week</a> reported an international trial of oral methylprednisolone involving 262 patients (including Australians) was stopped early due to safety concerns. Although the drug resulted in an almost three fold lower risk of kidney failure, there was an almost five fold higher risk of serious infection. The researchers reported two patients had died from these trial-related infections.</p>
<p><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1415463#t=article">Other clinical trials</a> have also reported higher rates of adverse effects, like serious infections, from oral use of methylprednisolone when treating IgA nephropathy.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/kidneys-are-amazing-for-all-they-do-be-sure-to-look-after-yours-30966">Kidneys are amazing for all they do, be sure to look after yours</a>
</strong>
</em>
</p>
<hr>
<p>However, for people prescribed the drug for other reasons side effects are rare. And methylprednisolone should not to be confused with similarly sounding medicines in the same drug family, like prednisolone or prednisone.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/180658/original/file-20170802-7559-8dnmh2.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180658/original/file-20170802-7559-8dnmh2.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=812&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180658/original/file-20170802-7559-8dnmh2.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=812&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180658/original/file-20170802-7559-8dnmh2.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=812&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180658/original/file-20170802-7559-8dnmh2.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1021&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180658/original/file-20170802-7559-8dnmh2.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1021&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180658/original/file-20170802-7559-8dnmh2.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1021&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<h2>Use and formulations</h2>
<p>Methylprednisolone is a type of <a href="http://www.medicinenet.com/corticosteroids-oral/article.htm">corticosteroid</a>, the same drug family containing hydrocortisone, dexamethasone, prednisone, prednisolone and triamcinolone.</p>
<p>Corticosteroids are not the same as <a href="https://www.drugabuse.gov/publications/drugfacts/anabolic-steroids">anabolic steroids</a>, which some athletes and body builders use illegally to build muscle and help performance.</p>
<p>Corticosteroids suppress inflammation and the immune system by <a href="https://www.yourgenome.org/facts/what-is-gene-expression">regulating how genes are expressed</a>.</p>
<p>In Australia, methylprednisolone is indicated for acute severe asthma, arthritis (including both rheumatoid and osteoarthritis), <a href="http://www.move.org.au/Conditions-and-Symptoms/Gout?gclid=CjwKCAjwzYDMBRA1EiwAwCv6JrreALKZbjLvlHyyzXDXWtCMQOCcowEcp8TXDGQdja2F9fdUaZrfMBoCAxMQAvD_BwE">gout</a> (an arthritis-like condition due to the build up of uric acid in the bloodstream), <a href="http://www.webmd.com/fitness-exercise/arthritis-tendinitis#1">tendinitis</a>, acute transplant rejection, and some autoimmune diseases, like allergies, <a href="https://www.allergy.org.au/patients/skin-allergy/eczema">eczema</a> and <a href="http://www.psoriasisxplained.com.au/psoriasis-app-page/?utm_source=Adwords&utm_medium=Advert&utm_campaign=launch&gclid=CjwKCAjwzYDMBRA1EiwAwCv6JjRBx5XwiFqZA1GsBO0BCy0UJxbKAu9WRRk1c54r0Dl0u6lQgUAp0hoCTS0QAvD_BwE">psoriasis</a>.</p>
<p>Methylprednisolone is also on the <a href="http://www.who.int/topics/essential_medicines/en/">World Health Organisation’s list of essential medicines</a> that:</p>
<blockquote>
<p>… satisfy the priority health care needs of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness.</p>
</blockquote>
<p>The most <a href="http://www.who.int/medicines/publications/essentialmedicines/20th_EML2017.pdf?ua=1">up-to-date list</a> published in March 2017 includes methylprednisolone for the treatment of acute lymphoblastic leukaemia. The list also includes the related drug, <a href="https://beta.nhs.uk/medicines/prednisolone/">prednisolone</a>, to treat different types of leukaemia and lymphoma.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-can-go-wrong-in-the-blood-a-brief-overview-of-bleeding-clotting-and-cancer-76400">What can go wrong in the blood? A brief overview of bleeding, clotting and cancer</a>
</strong>
</em>
</p>
<hr>
<p>While methylpredisolone is available in other countries in tablet form, in Australia it is only available by prescription as an injection or as skin cream or ointment. As an <a href="http://www.pharmexec.com/what-happens-when-product-loses-its-patent">off-patent</a> medicine, it is available from a variety of companies in different brands. </p>
<h2>Safety and side effects</h2>
<p>The <a href="https://amhonline.amh.net.au/">Australian Medicines Handbook</a> (subscription required) says side effects should be rare (have a rate less than 0.1%), the most common of which is liver toxicity. It is safe for women to use immediately after breastfeeding, but they should avoid using it within four hours before breastfeeding. This is because very small amounts of the drug can be transferred into the milk.</p>
<p><a href="https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2014-CMI-02603-1">Other side-effects</a> depend on the dose and the formulation used. When used on the skin, side effects can include: thinning of the skin, appearance of fine blood vessels, acne, infection of hair follicles, excessive or unwanted hair growth, redness around the mouth, skin discolouration and allergic skin reactions.</p>
<h2>In a nutshell</h2>
<p>Methylprednisolone is an effective and safe medicine for treating inflammatory and autoimmune conditions. Recent studies into its use for IgA nephropathy have indicated an unacceptably high risk of serious infection. </p>
<p>Despite this, you should not be at risk if you use the medication as directed and prescribed by your doctor. However, if you have any concerns, you should speak to your local pharmacist.</p><img src="https://counter.theconversation.com/content/81893/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is affiliated with the Royal Australian Chemical Institute.</span></em></p>A trial of methylprednisolone in kidney patients was halted recently because of safety concerns. But this doesn’t affect people taking the drug for asthma, arthritis or other inflammatory conditions.Nial Wheate, BPharm Coordinator and Senior Lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.