Steroids have place in modern medicine

Conway McLean, DPM, Journal columnist

Advances in pharmacology have provided tremendous benefits to humanity in improved health, longevity and quality of life. Although much controversy now exists regarding our current dependence on the prescribing of pharmaceuticals as a primary form of therapy, there is no denying drugs have changed the course of history. This may sound overly dramatic, but it doesn’t take much analysis to see the truth in this.

Have you ever had any dental work done? Most of us can answer ‘yes!’ Where would we be without local anesthetics? Any surgical specialist is especially fond of this class of medicine since it allows us to perform all manner of operative treatment without the pain and trauma that would otherwise ensue. Something as simple as the removal of a suspicious mole, a procedure I perform on a routine basis, would be quite uncomfortable, and often emotionally traumatic, without the use of a “local.” Many would opt not to have this procedure, resulting undoubtedly in more undetected melanomas!

Probably the first class of drug most would mention in this discussion is that of antibiotics. The discovery of penicillin was a major breakthrough, and subsequently lead to the day when infection was no longer a primary cause of mortality. Antibiotics continue to be a commonly prescribed medication (too commonly?), but obviously there are so many others. We now have a drug for seemingly every possible ailment, malady, condition or concern in existence. Many would argue the benefits of this approach to well-being, but there is no dispute the pharmaceutical industry is an integral part of the U.S. health care system.

Neither of these examples are the subject of today’s treatise. Instead, it is a class of medication prescribed on a daily basis, used for a great variety of medical conditions. It is likely you would be shocked at the numerous uses. Most of us have had occasion to avail ourselves of its many positive effects. Have you ever had a rash? Do you suffer from some type of arthritis? Or perhaps you have a digestive disorder. Many people have problematic allergies. For these conditions and many others, a steroid of some type is commonly prescribed.

Everyone has heard of cortisone, and many have had this drug administered. Strangely, despite its ubiquitous use, most have no idea what it is and how it works. For example, were you aware cortisone is a naturally occurring substance, produced by the human body? Often when administration of this medication is recommended by a physician, a common reaction from people is one of refusal, the thinking being this is a dangerous substance, certain to cause complications. Because it is so commonly recommended, it would seem wise to delve further into this topic.

Cortisone is a member of a group of substances termed the glucocorticoids, which, in turn, is a type of corticosteroid. Pharmaceutical corticosteroids mimic the effects of hormones naturally produced by your adrenal glands, which sit on top of your kidneys. When given orally or by injection, the drug is distributed throughout the body. They influence the body in several ways, but most importantly, they act on the immune system, functioning to reduce inflammation. They do this by keeping your immune system from making substances that cause inflammation, just like the naturally occurring form of cortisone does.

Because of this action on inflammation, they are used to treat a plethora of conditions. This list includes many types of arthritis, colitis, asthma, bronchitis and various dermatologic problems. Some other common uses include the treatment of vasculitis, lupus, even gout. As you may notice, all of these are inflammatory problems. Many skin diseases produce this reaction by the body, so these are very frequently prescribed for dermatologic problems.

Only when prescribed in doses that exceed your body’s usual levels will corticosteroids suppress inflammation. The anti-inflammatory effects of the corticosteroids are complex, and involve various cellular and biochemical changes. Some of the most obvious pharmacological effects of corticosteroids are seen on blood vessels, where they cause vasoconstriction (narrowing of blood vessels). As appropriate, this is in direct opposition to the effects of inflammation, with its characteristic redness and heat, all clinical signs of opened blood vessels, ie vasodilation.

Of course, another source of confusion is the use of a certain type of steroid by bodybuilders. These are termed anabolic steroids. Obviously, these drugs have a very different effect, including a shift in metabolism towards muscle growth. As with most every drug, there are side effects, which include alterations in mood, skin problems, hair loss and heart disease. Whereas some agents cause problems rarely or unpredictably, anabolic steroids will reliably cause these problems to develop eventually.

For many, their experience with steroids is in the form of an injection for a painful joint. The initial relief offered by a “steroid” injection is from the local anesthetic included in the syringe. Most of the steroids used in joint injections will kick in only after a few days. How long they last is the result of many factors. Generally you can expect a steroid to help for at least a few weeks, and often longer, sometimes a few months. Again, a multitude of factors effect this, including blood flow, metabolism and, very importantly, the cause. If the source is acute, and not a chronic condition, the injection may seem to “cure” the problem.

Yet, inflammation is an integral part of the healing process. Interfering with it, reducing it, may not always be the best long term solution. If the cause is biomechanical, there will reliably be recurrence. Steroids are wonderful for providing some immediate relief, but the source of the inflammation needs to be determined. Repeatedly injecting a painful body part, and expecting a cure, is misguided.

Like any medication, these can cause problems when used incorrectly or excessively. It is true, medicinal steroids have the potential for complications. Many people have a steroid flare, which causes temporary pain after an injection. More serious is tissue atrophy, the thinning and weakening of a tissue subjected to multiple steroid injections without sufficient time between. This is not a concern when different sites are treated, unlike oral or IV administration.

Use of these drugs via these latter routes can disturb your hormonal system, and thus produce many complications. These include such disparate effects as confusion, excitement, headaches, nausea, vomiting, and more. Over a longer term, high doses of steroids, given frequently, might lead to side effects including weight gain, mood changes, sleep disturbances, high blood pressure and thinning of the bones – all of these more likely with pills than injections.

Steroids are commonly prescribed, and clearly have their place in modern medicine. But when they are relied on as the primary method of care, and the cause of the inflammation is not determined (or can’t be discovered), they are only a temporary solution. Unfortunately, in our current system of medicine, sometimes simply reducing the symptoms is the best we can hope for. I believe we should be striving for more.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with an upcoming move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments at