What are the effects of high-dose steroids on mastitis?

High-Dose Steroids for Mastitis Treatment

Topical and intralesional steroids are effective first-line treatments for idiopathic granulomatous mastitis, offering high efficacy with minimal side effects and low recurrence rates compared to surgical approaches. 1

Types of Mastitis and Steroid Effectiveness

• Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory breast condition characterized by non-caseating granulomas that responds well to steroid therapy 2
• Local steroid treatment (LST) including topical and intralesional administration has shown 97% response rate in IGM cases 1
• Topical steroids effectively reduce inflammation in breast tissue and skin lesions, with complete resolution typically occurring within 8 weeks 3

Steroid Administration Methods for Mastitis

• Topical steroids can penetrate beyond the skin to affect mammary parenchyma, as demonstrated by MRI findings showing improvement in inflammatory patterns 3
• Intralesional steroid injections provide direct treatment to affected areas, reducing lesion size from a median of 23.5mm to 16mm after just one treatment session 1
• Combined therapy (systemic plus topical) shows similar efficacy to either method alone but may increase systemic side effects compared to topical-only treatment 4

Dosing Considerations

• For systemic treatment of IGM, prednisolone at 0.5-1 mg/kg/day is typically used, with treatment duration of 4-6 months depending on symptom severity 5
• Topical steroid treatment may require longer duration (average 22 weeks) compared to systemic treatment (11.7 weeks) but has significantly fewer systemic side effects (2.4% vs 38.2%) 4
• High-dose systemic steroids should be tapered with addition of pregnancy-compatible drugs if needed during pregnancy 6

Cautions and Side Effects

• Systemic steroids carry risks including lipodystrophy, hypertension, cardiovascular disease, osteoporosis, impaired wound healing, myopathy, cataracts, peptic ulcers, infection, and mood disorders 6
• Long-term use of high-dose steroids (prednisone ≥20 mg daily) is associated with reduced bone mineral density and increased fracture risk 6
• During pregnancy, stress-dose steroids should be avoided for vaginal delivery but may be appropriate for cesarean delivery 6

Special Considerations for Lactating Women

• For mastitis during lactation, non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, diclofenaco, and naproxeno are generally considered safer first-line options 7
• If steroids are needed during breastfeeding, prednisone or non-fluorinated steroid equivalents <20 mg daily are considered compatible with breastfeeding 6
• For prednisone doses ≥20 mg daily, mothers should discard breast milk obtained within 4 hours following medication administration 6

Treatment Algorithm for Mastitis

1. For non-granulomatous mastitis during lactation:

   • First-line: NSAIDs like ibuprofen 7
   • Avoid high-dose systemic steroids unless absolutely necessary 6

2. For idiopathic granulomatous mastitis:

   • First-line: Topical or intralesional steroids due to high efficacy (97%) and minimal systemic effects 1, 4
   • Second-line: Low-dose systemic steroids (0.5-1 mg/kg/day) if topical treatment is insufficient 5
   • Surgery should be reserved for cases that fail medical management due to higher recurrence rates (31.2% vs 0% with LST) 1

3. During COVID-19 or other infectious disease concerns:

   • Low-dose corticosteroids (<1 mg/kg/day) can still be used for IGM treatment without significant impact on infection risk 5

Monitoring and Follow-up

• Regular clinical and radiological evaluation is recommended to assess treatment response 3
• MRI with time-intensity curve patterns can help monitor treatment effectiveness, with shift from Type 2/3 to Type 1 patterns indicating improvement 3
• Monitor for potential steroid-related complications, especially with systemic administration 6