Transcript
Dr. Naiem Issa: Hello, everybody, and welcome to our program today. My name is Dr. Naiem Issa. I'm a board certified dermatologist in Northern Virginia, and I'm also Professor of Dermatology at the George Washington University School of Medicine, as well as the University of Miami School of Medicine. And joiningme today is my wonderful colleague, Dr. Maureen Offiah.
Dr. Maureen Offiah: Hi, everyone. Thank you for joining us today. Dr. Issa, thank youfor having me. My name is Dr. Maureen Offiah. I'm a board certified dermatologist in Hattiesburg, Mississippi. I work for a large multi-specialty group here that covers mostof South Mississippi. And I'm also an affiliate professor at the University of Mississippi Medical Center in the Department of Dermatology, where I help train the dermatologyresidents in dermatologic surgery at the VA Medical Center in Jackson, Mississippi.
Dr. Naiem Issa: Thank you, Dr. Offiah. So what that means to everybody is that y'all are going to learn today from Dr. Offiah. Thank you so much for being here with us. So Dr. Offiah, as we get started with today's session, the first thing I would like to talkabout is the concept of steroid stewardship. Is that a concept you've heard of before?
Dr. Maureen Offiah: Yes, absolutely, and it's a concept that's becoming more and more important as we go in practice. It's becoming louder and we hope to keep spreading that message. Steroid stewardship is for dermatologists what antibiotic stewardshipis for hospitalist and infectious diseases physicians. So it's our responsibility notjust as dermatologists, but also just as physicians in general to do no harm, treat our patients with the safest, most effective products, skincare medications, nonsteroidalmedicines whenever possible, trying to minimize the use of steroids, and justbasically managing and controlling how we use steroids in day-to-day practice.
Dr. Naiem Issa: Absolutely, and I totally agree with you. I think we are in the era ofthis steroid stewardship, especially since we've had decades of the steroid use, from topicals to orals, corticosteroids, and as well as intravenous and intramuscular. Steroids have been ubiquitous in dermatology as well as other specialties as well. And I think a lot of our audience may have had a lot of experience with steroids, probably even more than us, to be honest, at times. But let me ask you this, Dr. Offiah, why have we been using topical steroids? Give us a little bit about the mechanism there and why we may have used it for inflammatory dermatoses. And what I mean by that, the most common ones that we see in dermatology, including atopic dermatitis, psoriasis, as well as seborrheic dermatitis, we see these three almost every day in our clinics. Where have steroids fit in our treatments up till now?
Dr. Maureen Offiah: Historically, steroids were literally all that we had for years andfor decades. Since the discovery of hydrocortisone dating back to the 1950s, that was literally all we had as far as topical medications go. And yet steroids still remain some of the strongest anti-inflammatory agents, both in the systemic realm, and as well as the topical realm, in the sense that they're the best for decreasing the amount of inflammatory cytokines that play the key roles in the inflammatory dermatoses that we treat. So many, many years ago, that was all we had. And then as time went on, as we continued to discover that even though these medications that seem to workgreat, they were just not safe for long-term use. They were not safe for managing chronic lifelong conditions, because pretty early on after the discovery, all of the sideeffects associated with steroids started to come to light. We start seeing things like HPA axis suppression with systemic steroid use, and even inappropriate use of topicalsteroids in some scenarios. On the skin parts they're seeing atrophy, dyspigmentation, and everything else, striae and all the other associated side effects that go with inappropriate use of topical steroids. The bottom line was, we realized that for managing lifelong chronic diseases, steroids were just not the answer. They are great for acuteshort-term use for a brief period of time, like a rescue medication. But then what does the patient do after that? Beyond the two or three weeks of steroid use, what do the patients do? And that's where the nonsteroidals really come to play, because honestly, the key to keeping our patients healthier, feeling better symptomatically is really whatwe do in the maintenance phase and not so much what we do in the acute phase.
Dr. Naiem Issa: I think that is a fantastic logical way of actually posing what the patients are going through, the acute phase and the maintenance phase. And I'm going to come back to that in just a second, but I would like to give you a personalexperience actually that I have had. You brought up HPA axis suppression with topicals, and I actually had a case back in residency years ago where I had a patientwho was using topical triamcinolone on more than 50% of her body. This is an adult patient at that, and she ended up having a cushingoid phenomenon. She actually had striae, she actually had the buffalo hump, and she had her glucoseget out of whack and so on. So the key point is that at first, steroids may seembenign at the surface, but you do see these kind of textbook findings the moreyou treat. It's inevitable. And that's a case I never forgot actually.
Dr. Maureen Offiah: I tell young trainees or early career dermatologists, "If you haven't seen all of the horrific things that can come out from inappropriate use of topical steroid, it feels like you haven't practiced long enough."
Dr. Naiem Issa: Fair enough.
Dr. Maureen Offiah: It would eventually show up.
Dr. Naiem Issa: Right. And so just to add a little bit more mechanistic informationin terms of topical steroids, specifically while you have different strengths anddifferent formulations and what have you, they all converge on the same mechanism of action, same MOA, which is activation ... Sorry, I should say suppression ofthe glucocorticoid receptor, GR, which is a nuclear transcription factor. The keyreason why I bring this up is because this is a very non-specific mechanism. The way I describe this not just to my colleagues, but also to my patients is, "This isan atomic bomb on your immune system, whether it's topical or oral or systemic, whatever, because the MOA dictates it as such." This is not a precision medicine. Unlike what we have today, such as looking at phosphodiesterase four, for example, which we'll come to that in a second. So we know the potential side effects. Weknow that the MOA also leads to the potential side effects. We know this is very well established. So we have now a story to tell for not just each other and our clinician friends and colleagues and trainees, but also the patients. And on top of that, I really believe that what we see in clinic is these patients are coming in already asking forsomething that is not a steroid. Is that something that you're seeing in your practice?
Dr. Maureen Offiah: Oh, absolutely. In fact, the penultimate patient that I saw this afternoon before I came to set up for the program was a 22-month-old baby, whose mother just came in and she was ... I mean, this baby was literally covered head to toe with inflammatory eruptions of atopic dermatitis. And her mom was just adamant. She just said, "No steroids," and she said "No systemics." I mean, she just came in saying she didn't want any of that. So we're finding that more and more patients are coming in with this steroid phobia, if you will. Steroid phobia is one thing, but also steroid awareness is the other thing. Thanks to social media that's blown up since the pandemic, our patients are being more aware of thetypes of medications that they use and the ingredients and the side effects that could potentially arise from that. And they're coming now armed with a lot more knowledge, if you will, and they're just demanding no steroids in their treatment. Sothis is something that I see several times a week, but it's crazy that you mentioned it because literally the patient I just saw less than an hour ago was the same thing. Mom was just adamant and she wasn't going to have it.
Dr. Naiem Issa: Right. I absolutely agree with you and I see this day in and day out. And with the omnipresent artificial intelligence, omni AI, I guess is what I'll call it, with our ChatGPT on one hand and Claude, our French buddy on the otherhand, these patients, they're coming in and they're looking this up and telling us in the room about the dangers of steroids and why they don't want them. And especially parents. I don't know if you see children, but in my practice for atopic derm, specifically in seborrheic dermatitis. I don't see as much pediatric psoriasis, but for AD and seb derm, I do have a lot of these kiddos and it's been a tough line to walk.
