Dr Jennifer Miller Outlines Challenges of Corticosteroid Use in Pediatric Skin Conditions

Jennifer Miller, MD, a pediatric endocrinologist at Lurie Children's Hospital, went over the myriad of challenges associated with systemic corticosteroid use in pediatric patients with dermatologic conditions, including adrenal suppression and growth delays.

Miller presented at the Society for Pediatric Dermatology 2024 annual conference in Toronto, Canada on the subject, addressing how caregivers and providers can help manage patients in need of these medications.

Transcript

Under what circumstances should systemic corticosteroids be avoided in pediatric patients?

So, in general, I think there's always balancing risks and benefits of systemic steroids because they can have great treatment effects, and they can have a lot of side effects. I just think they should be avoided when that balance does not give you the treatment effects you're looking for, because then it's not worth the side effects.

What are the potential short-term and long-term side effects of systemic corticosteroid use in pediatric patients?

They can be vast and varied. They can include high blood pressure, high blood sugars, or risk of diabetes. They can include suppressing the hypothalamic pituitary adrenal axis, and then things like mood changes, skin changes, like acne or stretch marks, or hirsutism, or hair growth. Additionally, eye problems like cataracts or glaucoma. You're going to have muscle problems like achy muscles, like myopathy, who didn't have lack of linear growth, like suppressing the ability to grow taller, and osteoporosis, broken bones, just to name a few.

How do you address concerns from parents about potential growth delays due to corticosteroid use?

I think that's super important, and that goes back to balancing the risks and benefits, because a lot of times whatever it is you're treating with steroids would cause terrible growth delay itself if you did not treat it. So if you leave something untreated that has a lot of inflammation, you're not going to grow well. If you're able to get it under control with steroids and then wean the steroids back, but it's still under control, then the growth delays from steroids are going to be less because you're able to wean it back. So the real growth delays are usually seen with chronic steroid use, not with a few days here and a few days there. But they are real. I mean, if you need steroids for years, you are not going to grow. But if you don't treat something with steroids that needed treatment, you are not going to grow. So it's just a balance always.

How do you manage rebound symptoms or flares after discontinuation of systemic corticosteroids?

It depends which one you're talking about. If you're talking about a flare of the primary disease, then whoever treated the primary disease should treat that disease, including considering going back on the steroids. If you're talking about withdrawal, like steroid withdrawal symptoms, which are usually from coming off or coming off quickly, or just because your body didn't tolerate it, then we go to what your last tolerated dose was and then we knew much more slowly off to allow your body time to adjust to changes in how much steroid it's seeing.

How can health care providers minimize the risk of adrenal suppression in children taking systemic corticosteroids?

So, we think that you would get adrenal suppression if we've used steroids for at least 2 weeks in a row or at least 30 days in the last 6 months. So the best way to avoid it is to not need as much steroids, but if you need steroids, you can't avoid it. I think what's more important is recognizing it and knowing and being able to have a backup plan of stress dose steroids for times of illness, so that families are armed with everything they need if their child is sick, and they've been on steroids and they have adrenal suppression.