Steroids and Their Relationship to Vasculitis and Cellulitis
Steroids can be used to treat certain types of vasculitis but do not typically cause vasculitis; however, they may increase the risk of cellulitis through immunosuppressive effects and skin changes.
Steroids and Vasculitis
Therapeutic Role in Vasculitis
Steroids are a cornerstone treatment for many types of vasculitis rather than a cause:
- In giant cell arteritis and Takayasu arteritis, high-dose steroids are recommended as first-line therapy to reduce recurrent stroke risk 1
- For primary CNS angiitis, glucocorticoids are used for induction therapy, often followed by steroid-sparing immunosuppressants 1
- In ANCA-associated vasculitis, high-dose systemic steroids combined with other immunosuppressants are used to rapidly induce remission 1
Steroid Dosing in Vasculitis Treatment
- Initial high doses (often 1 mg/kg/day or pulse therapy) are used for induction of remission
- Slow tapering is recommended to prevent disease flares
- For giant cell arteritis, a target of ≤5 mg/day after 1 year is reasonable 1
- Steroid-sparing agents are often added to reduce long-term steroid exposure 1
Steroids and Cellulitis
Risk of Cellulitis with Steroid Use
Steroids can potentially increase the risk of cellulitis through several mechanisms:
- Immunosuppressive effects that impair host defenses against bacterial infections 2
- Skin atrophy and fragility that may create portals of entry for bacteria 1
- Impaired wound healing that prolongs skin barrier disruption 1
Evidence for Steroid-Associated Cellulitis Risk
The American Academy of Dermatology guidelines note that prolonged use of high-potency topical corticosteroids can cause:
- Skin atrophy
- Purpura
- Telangiectasia
- Striae These changes may increase susceptibility to skin infections 1
Steroid Use in Cellulitis Treatment
Interestingly, steroids may sometimes be used adjunctively in cellulitis treatment:
- A randomized trial showed systemic corticosteroids could attenuate inflammatory reaction and hasten resolution of uncomplicated cellulitis 1
- In orbital cellulitis, a small study (n=21) showed adjunctive oral steroids after initial antibiotic response may hasten resolution of inflammation 3
- However, a Cochrane review concluded there is insufficient evidence for routine use of corticosteroids in periorbital and orbital cellulitis 4
Important Clinical Considerations
Monitoring Patients on Steroids
Patients on long-term steroids should be monitored for:
- Infections, particularly in elderly or immunocompromised patients 2
- Neutrophil and lymphocyte counts 2
- Hypothalamic-pituitary-adrenal axis suppression 1
- Bone density (osteoporosis risk) 1
Reducing Steroid-Related Complications
- Use steroid-sparing agents when possible (methotrexate, azathioprine, mycophenolate mofetil) 1
- Consider prophylaxis against infections in high-risk patients 2
- Minimize periocular steroid use to reduce risk of cataracts/glaucoma 1
- Avoid prolonged use of potent topical steroids on the face or intertriginous areas 1
Diagnostic Considerations
Differentiating Vasculitis from Cellulitis
- Leukocytoclastic vasculitis can sometimes be mistaken for cellulitis 5
- Key differences:
- Vasculitis often presents with palpable purpura rather than diffuse erythema
- Bilateral and symmetric involvement is more common in vasculitis
- Failure to respond to antibiotics should prompt consideration of vasculitis
- Skin biopsy is required to diagnose vasculitis 5
When to Suspect Steroid-Related Complications
- Development of skin infections during steroid therapy
- Worsening of existing infections despite antibiotic therapy
- Atypical presentations of common infections
- Opportunistic infections
In summary, while steroids are a mainstay treatment for many types of vasculitis, they can potentially increase the risk of cellulitis through immunosuppression and skin changes. Careful monitoring and appropriate preventive measures are essential when using steroids long-term.