Chapter 7 Steroid Withdrawal Support Doctor in Beverly Hills - 2
The below is the Dr. Rapaport’s paper continued from the previous chapter.
----- Excerpt -----
Corticosteroid Addiction Patterns
Approximately 90% of our patients had a history suggestive of atopy. The only significant variation from this pattern occurred in patients with facial dermatitis of whom approximately 20% had seborrheic dermatitis or “dry skin.”
When dermatitis first developed in these patients, many of them self-prescribed over-the-counter 1% hydrocortisone cream or ointment.
For those who sought medical consultation, many had been given moderate strength corticosteroids initially, and in the past 5 years, super potent corticosteroid preparations were commonly prescribed at the outset. When pruritus or rash persisted or when rash recurred, stronger corticosteroids or more frequent application was recommended.
As skin complaints worsened, but now accompanied by burning, systemic corticosteroids, e.g., IM triamcinolone or betamethasone, were administered from 2 to 8 times a year. Patients with red face syndrome, actinic dermatitis, and multi sited atopic rashes commonly received this therapy. In addition, oral prednisone 20–80 mg/ day was sometimes prescribed for varying periods of time.
In these initial phases of the addictive process, the corticosteroids were usually effective, and patients felt relief for weeks to months. As time passed, however, many patients required systemic corticosteroids at more frequent intervals, some every 6 to 10 weeks. Daily topical treatment only maintained tolerance of symptoms and mild diminution of the rash. Patients complained that corticosteroids “were not working anymore.” It was at this time that the authors were consulted.
By this time, the initial limited areas of dermatitis had expanded significantly. The itch had mostly disappeared but had been replaced by severe burning that was only relieved by further topical corticosteroid application.
The appearance of the dermatitis changed and was now more of a hyperemia. Most topical nonsteroidal preparations increased the burning, and this led patient and physician to believe that an occult allergen was the cause. In fact, in many cases the purpose of the initial referral was to identify that obscure allergen. This “addictive phase” took from 3 months to several years to develop.
----- End of excerpt -----
I can read every statement nodding as I have experienced the same things through treating or rather supporting hundreds of patients as described above. But it may just sound like a fictitious threat for those who have never seen such patients.
Suppose the dermatology clinic is a liquor shop and steroids are liquors. We seldom see alcoholics shopping at a liquor shop, don’t we? For most people alcoholic beverages are delicious and make them feel happy in drinking. However, it is also true there exist a large number of alcoholics. Dr. Rapaport is, or I was, consulted by “alcoholics” who come one after another hoping to stop drinking.
Supporting such patients is really tough. I used to think why I had to have such a hard time. To begin with, why didn’t a liquor shop advise a customer to take care not to be addicted? Isn’t it natural that I think so? But liquor shop owners would not listen to me.
They used to say; “We have run the store for decades and never seen addictive patients. Do you know how much profit we can get from selling a bottle of alcohol? We cannot afford to explain about addiction to each customer. We have to handle as many customers as possible to keep our business going. “
What disappointed me most was that clinical professors leading and governing dermatology in Japan seemed to have no experience of having seen steroid addicted patients and withdrew them from addiction. I’m not sure about the current situation, but it was true 6 to 10 years ago when I stepped back from dermatology.
There might be clinical doctors who have not seen steroid addicts, and I understand the reason why they are reluctant to get involved in addictive cases even though they noticed them. But isn’t it a duty for clinical professors to detect and academize a new pathological condition and update the medical text books accordingly?
Skin diseases are the most difficult, second to mental diseases to quantify the symptoms and dermatologists have to depend on clinical description for diagnosis. Therefore, dermatologists actively employ classical methods such as pattern recognition and descriptive science, which is the biggest factor that made me choose dermatology.
When I was an internal medicine intern more than 20 years ago, I was excited the way dermatologists diagnosed the collagen disease. They gave a diagnosis instantly just by looking at it, while internal medicine doctors checked diagnosis criteria one by one to make a diagnosis. At the case consideration session I participated for the first time after switching to dermatology, I was impressed to see the professors quickly make a diagnosis by means of pattern recognition looking at the clinical slides projected one after another.
It’s strange that dermatologists with such a sharp eye fail to notice the phenomenon of steroid addiction.
I can accept or at least understand the mentality of dermatologists who choose to keep silent to avoid pain even though they notice the problem.
But who can proclaim that steroid addition is just a fantasy and an unscientific idea when they have not seen or have missed the patients suffering from the addiction?
The below is the Dr. Rapaport’s paper continued from the previous chapter.
----- Excerpt -----
Corticosteroid Addiction Patterns
Approximately 90% of our patients had a history suggestive of atopy. The only significant variation from this pattern occurred in patients with facial dermatitis of whom approximately 20% had seborrheic dermatitis or “dry skin.”
When dermatitis first developed in these patients, many of them self-prescribed over-the-counter 1% hydrocortisone cream or ointment.
For those who sought medical consultation, many had been given moderate strength corticosteroids initially, and in the past 5 years, super potent corticosteroid preparations were commonly prescribed at the outset. When pruritus or rash persisted or when rash recurred, stronger corticosteroids or more frequent application was recommended.
As skin complaints worsened, but now accompanied by burning, systemic corticosteroids, e.g., IM triamcinolone or betamethasone, were administered from 2 to 8 times a year. Patients with red face syndrome, actinic dermatitis, and multi sited atopic rashes commonly received this therapy. In addition, oral prednisone 20–80 mg/ day was sometimes prescribed for varying periods of time.
In these initial phases of the addictive process, the corticosteroids were usually effective, and patients felt relief for weeks to months. As time passed, however, many patients required systemic corticosteroids at more frequent intervals, some every 6 to 10 weeks. Daily topical treatment only maintained tolerance of symptoms and mild diminution of the rash. Patients complained that corticosteroids “were not working anymore.” It was at this time that the authors were consulted.
By this time, the initial limited areas of dermatitis had expanded significantly. The itch had mostly disappeared but had been replaced by severe burning that was only relieved by further topical corticosteroid application.
The appearance of the dermatitis changed and was now more of a hyperemia. Most topical nonsteroidal preparations increased the burning, and this led patient and physician to believe that an occult allergen was the cause. In fact, in many cases the purpose of the initial referral was to identify that obscure allergen. This “addictive phase” took from 3 months to several years to develop.
----- End of excerpt -----
I can read every statement nodding as I have experienced the same things through treating or rather supporting hundreds of patients as described above. But it may just sound like a fictitious threat for those who have never seen such patients.
Suppose the dermatology clinic is a liquor shop and steroids are liquors. We seldom see alcoholics shopping at a liquor shop, don’t we? For most people alcoholic beverages are delicious and make them feel happy in drinking. However, it is also true there exist a large number of alcoholics. Dr. Rapaport is, or I was, consulted by “alcoholics” who come one after another hoping to stop drinking.
Supporting such patients is really tough. I used to think why I had to have such a hard time. To begin with, why didn’t a liquor shop advise a customer to take care not to be addicted? Isn’t it natural that I think so? But liquor shop owners would not listen to me.
They used to say; “We have run the store for decades and never seen addictive patients. Do you know how much profit we can get from selling a bottle of alcohol? We cannot afford to explain about addiction to each customer. We have to handle as many customers as possible to keep our business going. “
What disappointed me most was that clinical professors leading and governing dermatology in Japan seemed to have no experience of having seen steroid addicted patients and withdrew them from addiction. I’m not sure about the current situation, but it was true 6 to 10 years ago when I stepped back from dermatology.
There might be clinical doctors who have not seen steroid addicts, and I understand the reason why they are reluctant to get involved in addictive cases even though they noticed them. But isn’t it a duty for clinical professors to detect and academize a new pathological condition and update the medical text books accordingly?
Skin diseases are the most difficult, second to mental diseases to quantify the symptoms and dermatologists have to depend on clinical description for diagnosis. Therefore, dermatologists actively employ classical methods such as pattern recognition and descriptive science, which is the biggest factor that made me choose dermatology.
When I was an internal medicine intern more than 20 years ago, I was excited the way dermatologists diagnosed the collagen disease. They gave a diagnosis instantly just by looking at it, while internal medicine doctors checked diagnosis criteria one by one to make a diagnosis. At the case consideration session I participated for the first time after switching to dermatology, I was impressed to see the professors quickly make a diagnosis by means of pattern recognition looking at the clinical slides projected one after another.
It’s strange that dermatologists with such a sharp eye fail to notice the phenomenon of steroid addiction.
I can accept or at least understand the mentality of dermatologists who choose to keep silent to avoid pain even though they notice the problem.
But who can proclaim that steroid addition is just a fantasy and an unscientific idea when they have not seen or have missed the patients suffering from the addiction?