Why does using steroids (topical, local injection, or systemic) affect wound healing?

Why Steroid Use Matters in Wound Care

Steroids significantly impair wound healing through multiple mechanisms: they suppress inflammation needed for normal healing, inhibit collagen synthesis and deposition, reduce growth factor production (particularly TGF-β and IGF-I), and increase susceptibility to wound infections—making steroid exposure a critical factor to assess in every wound care patient. 1, 2, 3

Primary Mechanisms of Impaired Healing

Collagen Synthesis Disruption

• Corticosteroids directly inhibit collagen production and reduce wound tensile strength by 30% in animal models at doses of 15-40 mg/kg/day 2
• Steroids decrease hydroxyproline (collagen) content in healing tissue, which is the structural foundation of wound repair 4, 3
• This effect occurs through suppression of fibroblast activity and reduced formation of granulation tissue 5

Growth Factor Suppression

• Methylprednisolone significantly decreases transforming growth factor-beta (TGF-β) and insulin-like growth factor-I (IGF-I) levels in wound fluid—both essential for normal healing 3
• These growth factors regulate cellular proliferation, collagen synthesis, and tissue remodeling during the healing cascade 4, 3

Inflammatory Response Inhibition

• Glucocorticoids suppress the inflammatory response, which paradoxically delays healing since controlled inflammation is necessary for debris clearance and cellular recruitment 4
• This anti-inflammatory effect increases infection susceptibility, compounding healing delays 1

Clinical Impact Based on Steroid Exposure Pattern

Acute High-Dose Steroids (<10 Days)

• Short-term high-dose systemic corticosteroids likely have no clinically significant effect on wound healing in most patients 2
• Single postoperative intralesional steroid injections do not statistically delay wound healing (17.1 vs 17.3 days healing time) 6

Chronic Systemic Steroids (≥30 Days)

• Chronic steroid use increases wound complication rates 2-5 times compared to non-steroid users 2
• Meta-analysis shows increased risk of all postoperative complications (OR 1.41,95% CI 1.07-1.87) and infectious complications (OR 1.68,95% CI 1.24-2.28) in IBD patients on steroids 1
• Adjusted pooled OR for postoperative infectious complications is 1.7 (95% CI 1.38-2.09) according to Cochrane review 1

Postoperative Steroid Dose Effects

• Postoperative steroid dose matters more than preoperative dose for wound dehiscence risk 5
• Patients with abdominal wound dehiscence received significantly higher postoperative steroid doses (404.3 ± 147.1 mg vs 135.6 ± 118.7 mg) and had prolonged healing (57.3 ± 18.0 vs 12.4 ± 3.8 days) 5

Practical Wound Care Implications

Assessment Priorities

• Document current steroid use: type, dose, route (topical/systemic/intralesional), and duration 1, 2
• Identify chronic users (≥30 days) as high-risk for complications requiring enhanced monitoring 2
• Calculate cumulative postoperative steroid exposure if surgery is planned 5

Topical Steroid Considerations

• Avoid applying topical corticosteroids directly to open wounds or erosions—use plain petrolatum ointment and bandages instead for local wound care 1
• High-potency topical steroids (clobetasol, betamethasone) are appropriate for intact skin in dermatologic conditions but should not be applied to wound beds 1, 7

Surgical Planning

• Steroid withdrawal is strongly recommended prior to elective surgery whenever possible 1
• When complete withdrawal is not achievable, progressive tapering to the lowest dose is essential 1
• Consider that thiopurines take 3 months to reach therapeutic levels and another 3 months to wash out, so immediate preoperative cessation has minimal impact 1

Common Pitfalls to Avoid

• Do not assume short-term steroids are safe in all contexts—susceptible individuals with comorbidities (diabetes, immunocompromise) may still experience impaired healing 2
• Do not apply topical steroids to wound surfaces thinking they will reduce inflammation—they inhibit the necessary healing response and should only be used on intact skin for specific dermatologic indications 1
• Do not overlook inhaled or topical steroid exposure—while systemic effects are less pronounced, chronic high-potency topical use can cause systemic absorption 7
• Do not continue high-dose steroids postoperatively without clear indication—the postoperative dose correlates more strongly with dehiscence than preoperative exposure 5

Special Populations Requiring Extra Vigilance

• Patients >60 years old have increased healing time even without steroids 6
• Immunocompromised patients show prolonged healing independent of steroid effects 6
• Patients with diabetes or hypertension may benefit from steroid-sparing alternatives when treating concurrent dermatologic conditions 1