Corticosteroid Use Guidelines

Introduction to Corticosteroid Use

• The American Academy of Dermatology recommends using low to medium-potency (class 5-7) corticosteroids, such as hydrocortisone 1-2.5%, desonide 0.05%, and alclometasone 0.05%, to avoid high-potency steroids due to increased risk of skin atrophy, telangiectasia, and rosacea 1
• The American Academy of Dermatology suggests once or twice daily application of corticosteroids 1

Ocular Complications and Monitoring

• The American Academy of Ophthalmology states that baseline and periodic intraocular pressure (IOP) checks are required when using corticosteroids, due to the risk of increased intraocular pressure, glaucoma, cataract formation, and delayed wound healing 2
• The American Academy of Ophthalmology recommends regular monitoring of IOP and pupillary dilation to evaluate for glaucoma and cataract development, with follow-up every 3 months for chronic use 2
• Topical steroids can mask signs of corneal infection, and their use should be carefully considered 3
• Prolonged use of topical corticosteroids without tapering can lead to rebound inflammation, and regular intraocular pressure (IOP) checks are necessary, especially in known steroid responders 4, 5, 6

Alternative Therapies

• The American Academy of Ophthalmology suggests considering transitioning to topical calcineurin inhibitors (tacrolimus, pimecrolimus) for eyelid dermatitis, and topical cyclosporine for inflammatory eye conditions 2
• The American Academy of Dermatology recommends considering vitamin D analogs as adjunctive therapy, in addition to low-potency steroids for face/eyelids 1, 7
• After initial control of inflammation, transitioning to steroid-sparing agents such as ciclosporin drops for moderate-severe conditions or tacrolimus ointment for lid margin inflammation may be considered, based on recommendations from the British Journal of Dermatology 8
• For long-term needs, transitioning to steroid-sparing agents (cyclosporine or lifitegrast) is recommended after initial control of inflammation is achieved 6, 9

Treatment Duration and Frequency

• A brief course (3-5 days) of low-potency steroid is recommended, with transition to non-steroid options when possible 2
• The American Academy of Dermatology suggests starting with low-potency steroids for 5-7 days, and considering tacrolimus 0.03% or pimecrolimus 1% for maintenance 2
• Initial dosing of corticosteroid eye drops should be several times daily (typically 2-4 times) to the affected eye(s), with short-term use (1-2 weeks) preferred to minimize side effects 4
• The American Academy of Ophthalmology recommends topical prednisolone acetate 1% every 1-2 hours initially, then taper based on response, with the goal of suppressing ocular inflammation and achieving an inactive disease state 10
• Before changing therapy, it is essential to rule out treatment nonadherence, infections, and masquerade syndromes, according to the American Academy of Ophthalmology 10
• The American Academy of Ophthalmology suggests initiating noncorticosteroid systemic immunomodulatory therapy (NCSIT) if topical steroids cannot be tapered below 2 drops/day within 3 months 10
• The European League Against Rheumatism recommends azathioprine and systemic corticosteroids for patients with inflammatory eye disease affecting the posterior segment 11
• For severe eye disease, the European League Against Rheumatism suggests adding ciclosporine A, infliximab, or interferon-α 11
• Topical corticosteroids should be used for brief courses (typically 1-2 weeks) and require minimal effective dose for the shortest duration possible, with tapering to avoid rebound inflammation, and should be supervised by an ophthalmologist when used for ocular surface inflammation 3, 4, 5
• Referral to ophthalmology is recommended for cases requiring more than 8 weeks of topical corticosteroid therapy, progressive loss of visual acuity, or inadequate response to initial therapy, as advised by the British Journal of Dermatology guidelines 8

Specific Corticosteroid Options

• Loteprednol etabonate 0.5% has shown efficacy in treating dry eye disease with minimal intraocular pressure effects 5
• Loteprednol etabonate 0.2% is effective and well-tolerated for allergic conjunctivitis 6
• Intravitreal corticosteroids (e.g., dexamethasone implant/Ozurdex) are effective for macular edema but have higher risk of IOP elevation and cataract formation, and are reserved for cases unresponsive to other treatments 12, 13
• The American Academy of Ophthalmology suggests using site-specific corticosteroids (loteprednol etabonate) when possible, and considering corticosteroids with limited ocular penetration (fluorometholone) to minimize side effects 4, 5, 6

Systemic Corticosteroids and Risks

• Systemic steroids carry additional risks, including gastric irritation requiring protection, potential bone density loss with prolonged use, immunosuppression, and metabolic effects 14
• Overuse in chronic conditions increases the risk of cataracts and glaucoma, and the solution is to consider steroid-sparing alternatives for long-term therapy 5, 6, 12
• Brief courses of topical corticosteroids may help control eyelid or ocular surface inflammation in blepharitis 15