Safety Considerations With Long-Term Use of Corticosteroids and Immunomodulators
An expert discusses how long-term corticosteroid use carries risks of skin atrophy, systemic effects such as adrenal suppression, and area-specific concerns such as increased intraocular pressure near the eyes. Additionally, topical calcineurin inhibitors have black box warnings for potential infections and malignancies despite their established safety profile.
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Long-term corticosteroid use in vitiligo treatment presents significant safety concerns, particularly skin atrophy and thinning. Areas with naturally thinner skin, including eyelids, armpits, groin, and other body folds, face higher risks due to increased absorption and enhanced corticosteroid effects. Eyelid treatment carries additional risks including elevated intraocular pressure and potential cataract formation, making practitioners extremely cautious about corticosteroid use in periocular areas and often necessitating rapid transition to noncorticosteroid alternatives for long-term management.
Beyond cutaneous adverse effects, extended topical corticosteroid use can cause telangiectasias, bruising, and steroid-induced acne, particularly on facial and chest areas. Systemic effects represent another concern, especially with large body surface area applications over extended periods, potentially leading to adrenal suppression and elevated blood glucose levels. In specific scenarios involving unstable, rapidly progressing vitiligo, practitioners may consider pulse dosing with systemic corticosteroids such as dexamethasone for disease stabilization, though this approach is uncommon.
Topical calcineurin inhibitors carry FDA black box warnings regarding potential infections and malignancies, specifically lymphoma risks. Despite established safety profiles and practitioner comfort with long-term use, these warnings can create prescribing barriers due to patient concerns. Additionally, topical calcineurin inhibitors demonstrate limited efficacy compared with newer treatments such as topical ruxolitinib, making the introduction of JAK inhibitors a significant therapeutic advance in vitiligo management.
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