Tag: adrenal suppression

Depression Reversal

Ever thought about our stomachs affecting our thoughts and emotions?

“There is a huge and growing everyday body of evidence connecting the health of the gut to the health of the brain. In fact, there’s a saying in functional medicine, fire in the gut, fire in the brain, which means that if you have inflammation, parasites, small intestinal bacterial overgrowth, fungal overgrowth, or dysbiosis in the gut, then that is going to produce an inflammatory response that in turn affects the brain and can cause inflammation and a whole bunch of other problems in the brain, and this is not a fringe theory at this point. It’s true that unfortunately not a lot of primary care doctors or even psychologists or psychiatrists are aware of this connection, but that doesn’t mean it isn’t well established in the scientific literature. It absolutely is. And in fact, it’s been known for almost a hundred years going back to some research that was done at Duke in the early 1930s and 1920s connecting the gut and the brain and even the skin in this axis—the gut–brain–skin axis, which I’ve written and spoken about before.”

This podcast goes into a lot of detail about how inflammation, anywhere in the body, can affect our minds (the frontal cortex).

Also, Kresser talks about the HPA axis, or the hypothalamic–pituitary–adrenal axis. If we’ve learned anything about topical steroid dependency, we know that overuse can lead to a suppression of the HPA axis. And then, add chronic, everyday stress to the situation, and you’ve got a system that is extremely overloaded.

The last big subject he touches on is deficiencies in the body that could be contributing to depression. If we are lacking in certain vitamins and aren’t using it optimally in the body (methylation issues) then it can be throwing our balance off.

I highly recommend this podcast if you wish to catch his more in depth explanations on depression and inflammation in the body. What we are eating and lacking in our diet could  the reason we are mentally suffering and struggling to get through certain situations.

Kresser Podcast on Anxiety

Topical Steroid Label Part II

Class 1 steroids, like Clobetasol Propionate, will always be the ones you see in studies showing bigger problems than less potent classes. However, that does not mean less point steroids are super safe.

So, I looked up the insert for the steroid I used, Alclometasone Dipropionate, which is a Class 6 steroid (Classes range from 1-7, 1 being the highest).

“May be used in patients 1 year of age and older, although safety efficacy of drug use for longer than 3 weeks have not been established.”

Not…. been… established. That translates into “we don’t know anymore after 3 weeks.” Also, it should NOT be used in children under 1 year old (although my personal belief is to steer clear of steroids on newborn skin).

The insert says to apply 2-3 times daily. We still see wavering views on this subject, some research showing putting on steroids creams more than once a day does not increase the likelihood of it working, but actually just increases your chances of overusing. Source

“If no improvement is seen within 2 weeks, reassessment of diagnosis may be necessary.” This doesn’t say “if this isn’t working we will just give you more potent steroids,” it states that there my need to be a reevaluation. Speak to your doctor about such matters because it is unbelievably important that you are diagnosed correctly. Perhaps you need a swab done to see if you have an infection? Or perhaps you are allergic to something inside the medication, or to a chemical or food you are use.

“In another study, Aclovate (alclometasone dipropionate) was applied to 80% of the body surface of a normal subjects twice daily for 21 days (3 weeks) with daily, 12 hour periods of whole body occlusion.” The HPA axis decreased 10% in these patients. This is a Class 6, mildly potent steroid, and within 3 weeks there was HPA axis suppression. First, 80% is almost full body, and some doctors will tell you to do that. Secondly, what is a normal subject? Someone with healthy skin? If so, someone with eczema will be even worse off since our skin barrier is damaged. Source

One of my favorite quotes is, “Topically applied Aclovate cream and ointment can be absorbed in sufficient amounts to produce systemic effects.” There is that word again: systemic. This Class 6, mildly potent steroid, can start affecting our adrenal glands. If a doctor says this isn’t true, hand them an insert.

This insert also says the same thing as Clobetasol Propionate regarding child toxicity and infection warnings. It also specified that it should not be used on diaper dermatitis.

“The following local adverse reactions have been reported…”

Who reports this? I never have. Where are these reports being made, or sent? Who sends them? Patients? Doctors? I know when I’ve stated adverse affects I’ve been told I was wrong by a doctor, so I know they weren’t reporting what I saw. I can only imagine that the list given is much smaller and/or incorrect due to lack of reporting.

But, check this out, you CAN do something: REPORT YOUR ADVERSE EFFECTS

Overall, there seems to be many unclear and unknown scientific facts about this steroid (most likely for all, but I can’t speak fairly on that since I have not read every single insert). Are we as patients supposed to be fine about this? When doctors tell us they are perfectly safe when we have concerns and see adverse affects, what evidence do they possess?

More research, management, and reporting must be done for the safety of patients.

Topical Steroid Label

Whenever we purchase a prescription, there is always an insert or attached label outlining that specific drug’s usage. More often than not, we toss it into the trash. What we should be doing is taking the time to read the insert because it holds extremely valuable information. However, on the contrary, there is misguided information that needs to be looked at closely.

The following is seen on the insert for Clobetasol Propionate, a Class 1 Super Potent steroid:

In bold letters: do not use for more than 2 weeks, 50g per week, because it can suppress the HPA axis.

First off, it warns not use to this for more than 14 days. What it does not say is “Do not use for more than 14 days unless your doctor thinks it’s cool.” There is a definite reason why it states that warning despite what your doctor tells you.

HPA axis suppression is not something you, or your doctor, should take lightly. You are highly increasing your chances of developing Red Skin Syndrome and creating an imbalance in your adrenal glands.

Also, what does 50g a week mean to you? Most likely nothing because you are not a doctor and have no idea how to measure out 50g.

Let’s say your doctor gave you a tube that was 60g large, and their instructions were to “use on flaring areas once a day.” That was it. That was all they told you. Well, your thighs, hands, elbow area, and neck are flaring. These areas combined, using the fingertip method, come out to around 10g a day of use. 10g x 7 days = 70g a week. That is over the maximum limit of use.

But let’s take this further. In bold, the insert states:

“Precautions: General: Clobetasol Propionate is a highly potent topical corticosteroid that has been shown to suppress the HPA axis at doses as low as 2g per day.”

2g per day! That is around 4 fingertip units a day.

2g x 7 days a week = 14g a week. So, more accurately, 50g a week is WAY too much. Even if 14g a week is seen as the ‘minimum’ to cause HPA axis suppression, that means THERE IS A POSSIBILITY it can happen with just 14g a week, which in turn shows there is a LARGE POSSIBILITY it will happen at the ‘safe usage’ of 50g a week.

That 36g difference is remarkable. This is something that rarely ever gets explained in a doctor’s office. When a doctor gives you the instruction to “use sparingly”, this is what they should be explaining to you.

But let’s move on.

When using steroids, adults are not equal to children.

“Pediatric patients may be more susceptible to systemic toxicity from equivalent doses due to their large skin surface to body mass ratios.”

First off, the word systemic should bounce out. If any doctor tells you that topical steroids “are not systemic”, they are lying to you. Just because you are not orally using them, does not mean they do not penetrate our skin and enter our system.

And two, this should put up a huge warning flag. If 14g a week is the lowest dose they saw suppression in for adults, try halving that, or even one quarter. That would be between 4g and 8g a week for small children and babies. And, because they are smaller, there is a larger chance of suppression. Besides, in bold caps, the insert says, “Use in children under 12 years of age is not recommended.” If a doctor prescribes this to a child under 12, especially a baby, know that this recommendation should read more as a forbiddance.

“If concomitant skin infections are present or develop, an appropriate antifungal or antibacterial agent should be used. If a favorable response does not occur promptly, use of clobetasol propionate should be discontinued until the infection has been adequately controlled.”

First off, you’ve got the vague “promptly” in there. Give us actual numbers, perhaps, “1-2 days”. And secondly, you should NEVER use steroids on an infection. It will just make them worse. Check out Tinea Incognito.

“#5 Patients should inform their physicians that they are using clobetasol propionate if surgery in contemplated.”

I had never heard of this before, so I do hope this information is shared in the doctor’s office and not left for the patient to (not) read in the insert.

And last, but certainly not least, in lovely bold writing, “should not be used on the face, groin, or axiliae”. This isn’t a recommendation. This is a definite warning.

Different Instructions for the Same Steroid

If things weren’t confusing or muddled enough, it has come to my attention that a steroid can have different recommendations in different countries. The steroid is the same and yet guidelines are blatantly different.

Let’s take Diprosone for example. This is a Betamethasone Dipropionate topical steroid.

In the UK, it states:

  • Do not use on any other skin problem as it could make it worse especially rosacea (a skin condition affecting the face), acne, dermatitis (skin inflammation) around the mouth, genital itching, nappy rash, cold sores, chickenpox, shingles or other skin infections. Ask your doctor or pharmacist if you are not sure.
  • Talk to your doctor or pharmacist before using diprosone ointment. This medicine should not be used under bandages or plasters.
  • Side effects that may happen with oral or injectables corticosteroids may also occur with corticosteroids used on the skin, especially in infants and children.
  • If the ointment is used more often than it should, or more than prescribed, it can affect some of your child’s hormones. This may affect their growth and development.
  • If Diprosone Ointment is used in children, it should not be used on any part of their body for more than 5 days.
  • Do not put the ointment under your child’s nappy, as this makes it easier for the active ingredient of the medicine to pass through the skin and possibly cause some unwanted effects.
  • Usually for adults and children, a thin layer of Diprosone Ointment should be rubbed into the affected area of skin twice a day.
  • Do not use the ointment on your face for more than 5 days.
  • Do not use a large amount of ointment on large areas of the body, open wounds or areas of the body where joints bend for a long time (for example every day for many weeks or months).
  • Most people find that when the ointment is used correctly, it does not cause any problems. However, if you use the ointment more than you should, particularly on your face, it can cause redness, stinging, blistering, peeling, swelling, itching, burning, skin rash, dryness of the skin, in the skin, inflammation of the hair follicles; excessive hair growth, reduced skin pigmentation; allergic skin reactions; dermatitis (skin inflammation); other skin infections, thinning of the skin and red marks.

In Australia, it states:

  • Do not use Diprosone if you have:

a viral skin infection, such as cold sores, shingles or chicken pox, a fungal skin infection, such as thrush, tinea or ringworm, tuberculosis of the skin, acne rosacea, inflammation around the mouth, skin conditions with ulcers,

Unless your doctor tells you.

(^^^^^^^ That seems unbelievably risky).

  • Do not use Diprosone just before having a bath, shower or going swimming.
  • Tell your doctor if: you are pregnant or breast feeding.
    Your doctor will tell you if you can use Diprosone during pregnancy or while you are breast feeding.

(^^^^^ again, whatever your doctor tells you? Why can’t the pamphlet tell me? Or is it that nobody knows and everyone is just guessing…)

  • Apply a thin film of Diprosone Cream or Ointment or a few drops of Diprosone Lotion to the affected skin or scalp twice daily. Massage gently until it disappears. For some patients, once daily application may be enough for maintenance therapy.
  • It is important to use Diprosone exactly as your doctor has told you.

(^^^^^ What if they tell you to go against the guidelines?)

  • Do not use Diprosone for more than four weeks at a time unless your doctor tells you.

(^^^^^^ And here is my point!)

  • Do not use Diprosone under dressings or on large areas of skin unless your doctor tells you

In the UK pamphlet, it says you should not use steroids on an infection site, even though the AU pamphlet says you can do it if your doctor instructs you to do so.

In the UK pamphlet, it says you should not use this steroid under occlusion, yet the AU pamphlet says it is ok if the doctor tells you to do so.

In the UK pamphlet, there doesn’t seem to be a set time recommendation to use the steroid (except for children and for the face), while the AU pamphlet says to use it no longer than 4 weeks unless your doctor says to do so, but doesn’t say how long to use it on the face.

In both pamphlets, it seems to leave pregnant women under the discretion of their doctor or their pharmacist.

Over and over in these pamphlets, there seems to be a lot of “just ask your doctor” or “unless prescribed by your doctor”. What happened to facts? What happened to “these are the guidelines and they need to be adhered to for the patient’s safety”? Moreover, there are doctors who get paid to prescribe certain drugs to patients, so where is the ethical line? Want to check out your doctor? Dollars for Docs

Also, RSS is not a side effect listed. It never is and should be. Red Skin Syndrome is not just a small symptom or side effect that will go away very quickly. This condition affects so much more than just your skin!

Doctors should also be educating their patients about steroid use, the good and the bad, as well as staying up to date with medical findings and research. Even a well meaning doctor can over prescribe this medication so it is pertinent that you know all there is about topical steroids before you begin use.

 

Medical Terminology Explained

One of the many ways we can feel left out of the medical loop is the jargon that leaves us perplexed and, most likely, uninterested in trying to understand our ailment. The doctor either says some fancy words or we end up reading a pamphlet that looks like ancient hieroglyphics. It can be daunting and when we just want relief, we don’t delve any further than the reaching to take a prescription from the doctor.

The time has come for us to decipher some very important medical terminology so we, as patients, can be best informed about our condition and what may lie ahead if we take a certain treatment.

Antiproliferative: of or relating to a substance used to prevent or retard the spread of cells, especially malignant cells, into surrounding tissues.

Atherosclerosis: a disease in which plaque builds up inside your arteries. This can cause different problems including coronary heart disease, carotid artery disease, and chronic kidney disease.

Atrophy: waste away, typically due to the degeneration of cells, or become vestigial during evolution. Picture

Axillae: Armpit

Bioethics: the study of the typically controversial ethical issues emerging from new situations and possibilities brought about by advances in biology and medicine. It is also moral discernment as it relates to medical policy and practice.

Corticosteroids: any of a group of steroid hormones produced in the adrenal cortex or made synthetically. There are two kinds: glucocorticoids and mineralocorticoids. They have various metabolic functions and some are used to treat inflammation. The ones we usually deal with are glucocorticoids that stop inflammation.

Candidiasis: infection by fungi of the genus Candida, generally C. albicans, most commonlyinvolving the skin, oral mucosa (thrush), respiratory tract, or vagina; occasionally thereis a systemic infection or endocarditis. It is most often associated with pregnancy,glycosuria, diabetes mellitus, or use of antibiotics. Picture

Concomitant: naturally accompanying or associated.

Cutaneous: of, relating to, or affecting the skin.

Demodicidosis: skin disease of the pilosebaceous units associated with human Demodex mites that involves predominantly the face and head. Picture

Edema: a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body. Picture

Efficacy: the ability to produce a desired or intended result.

Emollient: a preparation that softens the skin.

Erythema: superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries. Picture

Exacerbation: an increase in the severity of a disease or its signs and symptoms; a worsening.

Granuloma Gluteale Infantum: a rare skin disorder of controversial etiology characterized by oval, reddish purple granulomatous nodules on the gluteal surfaces. Picture

Gynecomastia: enlargement of a man’s breasts, usually due to hormone imbalance or hormone therapy. Picture

Hirsutism: abnormal growth of hair on a person’s face and body, especially on a woman. Picture

HPA axis: The hypothalamic–pituitary–adrenal axis is a complex set of direct influences and feedback interactions among three endocrine glands: the hypothalamus, the pituitary gland(a pea-shaped structure located below the hypothalamus), and the adrenal (also called “suprarenal”) glands (small, conical organs on top of the kidneys).

Hyperkeratosis: thickening of the stratum corneum (the outermost layer of the epidermis, or skin), often associated with the presence of an abnormal quantity of keratin, and also usually accompanied by an increase in the granular layer. Picture

Hyperpigmentation: the darkening of an area of skin or nails caused by increased melanin.

Hypertrichosifs: a skin abnormality that results in excessive growth of hair. It can be localized to one part of the body, or affect in full. It can affect men or women and is mostly secondary to a genetic disease that causes a hormonal disorder. Picture

Hypopigmentation: the loss of skin color. It is caused by melanocyte or melanin depletion, or a decrease in the amino acid tyrosine, which is used by melanocytes to make melanin. Picture

Iatrogenic: of or relating to illness caused by medical examination or treatment.

Immunosuppressive: (chiefly of drugs) partially or completely suppressing the immune response of an individual. Topically, there is Protopic and Elidel.

Impetigo: a contagious bacterial skin infection forming pustules and yellow, crusty sores. Picture

In vivo: (of a process) performed or taking place in a living organism.

Intertriginous: area where two skin areas may touch or rub together, like armpit or groin

Kaposi Sarcoma: a rare tumor that is named after the dermatologist who first described it in 1872. It is caused by a type of herpesvirus. Picture

Lichen Sclerosis: an uncommon condition that creates patchy, white skin that’s thinner than normal. Picture

Malassezia Folliculitis: an inflammatory skin disorder that typically manifests as a pruritic, follicular papulopustular eruption distributed on the upper trunk of young to middle-aged adults. Picture

Mastocytosis: disorder that can occur in both children and adults. It is caused by the presence of too many mast cells in your body. You can find mast cells in skin, lymph nodes, internal organs (such as the liver and spleen) and the linings of the lung, stomach, and intestine. Picture

Milia: a small white or yellowish nodule resembling a millet seed, produced in the skin by the retention of sebaceous secretion. Picture

Molluscum Contagiosum: a chronic viral disorder of the skin characterized by groups of small, smooth, painless pinkish nodules with a central depression, that yield a milky fluid when squeezed. Picture

Morbidity: is a term used to describe how often a disease occurs in a specific area.

Occlusive: Of or being a bandage or dressing that closes a wound and keeps it from the air.

Ocular Hypertension: an eye pressure of greater than 21 mm Hg. It usually occurs for a long time and doesn’t match with glaucoma.

Perioral Dermatitis: a common skin rash that mainly affects young women. The rash affects the skin around the mouth. Use of a steroid cream on the face seems to trigger the condition in many cases. Picture

Phimosis: a congenital narrowing of the opening of the foreskin so that it cannot be retracted.

Purpura: a rash of purple spots on the skin caused by internal bleeding from small blood vessels. Picture

Stellate Pseudoscars: white, irregular or star-shaped atrophic scars occurring over the sun-exposed areas of the forearms. Picture

Stratum Corneum: the horny outer layer of the skin.

Striae: a linear mark, slight ridge, or groove on a surface, often one of a number of similar parallel features. Picture

Synthetic: made by chemical synthesis, especially to imitate a natural product.

Systemic: of, relating to, or affecting the entire body.

Tachyphylaxis: rapidly diminishing response to successive doses of a drug, rendering it less effective. The effect is common with drugs acting on the nervous system.

Telangiectasia: a condition characterized by dilation of the capillaries, which causes them to appear as small red or purple clusters, often spidery in appearance, on the skin or the surface of an organ. Picture

Tinea Incognito: a fungal infection (mycosis) of the skin masked and often exacerbated by application of a topical immunosuppressive agent. The usual agent is a topical corticosteroid (topical steroid). Picture

Vasoconstriction: the constriction of blood vessels, which increases blood pressure.

Vitiligo: a condition in which the pigment is lost from areas of the skin, causing whitish patches, often with no clear cause. Picture