What is the role of steroids in treating allergies?

Role of Steroids in Treating Allergies

Steroids should not be used indiscriminately for allergic conditions but rather reserved for specific situations where their benefits outweigh potential risks. 1

Types of Allergic Conditions and Appropriate Steroid Use

Allergic Rhinitis

• First-line treatments: Antihistamines and mast cell stabilizers
• Steroid role: Intranasal corticosteroids are effective for persistent symptoms not controlled by antihistamines alone
• Administration: Topical intranasal route preferred over systemic administration 2
• Caution: Use at smallest effective dose for shortest possible time to minimize systemic absorption

Allergic Conjunctivitis

• First-line treatments: Topical antihistamines, mast cell stabilizers, or dual-action agents
• Steroid role: Ocular corticosteroids should be reserved only for severe symptoms
• Warning: Ocular side effects can be vision-threatening (cataracts, elevated intraocular pressure, secondary infections) 1
• Safer option: Modified steroids like loteprednol have reduced risk of increasing intraocular pressure

Food Allergies

• Not recommended: Current evidence does not support the use of pharmacologic therapy to prevent IgE-mediated food allergic reactions 1
• For acute reactions:
  • Mild symptoms (few hives, mild discomfort): Antihistamines
  • Severe reactions: Epinephrine is first-line treatment
  • Important: Steroids have limited benefit in acute food reactions and should not delay epinephrine administration 1
  • Steroids may be used as adjunctive treatment for severe reactions to potentially prevent biphasic reactions, but evidence is limited 1

Anaphylaxis Management

• First-line: Epinephrine (IM)
• Steroid role: Adjunctive only, not a substitute for epinephrine
• Timing: Corticosteroids have slow onset (4-6 hours) and are not helpful in acute anaphylaxis
• Duration: If used, treatment should be stopped within 2-3 days 1
• Evidence limitation: A 2015 study found that corticosteroid use in emergency departments for allergic reactions or anaphylaxis was not associated with decreased relapses to additional care within 7 days 3

Risks and Considerations

Adverse Effects of Systemic Steroids

• Suppression of hypothalamic-pituitary-adrenal axis
• Increased risk of infection with any pathogen
• Potential for reactivation of latent infections
• Metabolic effects (fluid retention, hypertension, hyperglycemia)
• Immunosuppression 4

Special Considerations

• Paradoxical reactions: Steroids themselves can rarely cause hypersensitivity reactions ranging from contact dermatitis to anaphylaxis 5, 6
• Diagnostic challenge: Difficult to distinguish between hypersensitivity reactions to steroids and worsening of the underlying inflammatory condition 6
• Transfusion reactions: Current recommendations advise against indiscriminate use of steroids for transfusion reactions 1
• Hoarseness/Laryngitis: Steroids are commonly prescribed but not supported by evidence except in specific circumstances like allergic laryngitis in performers 1

Practical Approach to Steroid Use in Allergies

1. Assess severity and type of allergic reaction
2. For mild allergic symptoms: Use antihistamines as first-line treatment
3. For moderate-severe persistent allergic rhinitis: Consider topical nasal steroids
4. For severe allergic conjunctivitis: Consider short-term ocular steroids under ophthalmologic supervision
5. For anaphylaxis:
   • Use epinephrine as first-line treatment
   • Consider short-course systemic steroids (2-3 days) as adjunctive therapy only
6. For chronic allergic conditions: Refer to an allergist for comprehensive management including allergen identification and avoidance strategies

Remember that steroids should be used at the lowest effective dose for the shortest duration possible to minimize adverse effects, and topical administration is preferred over systemic when appropriate.