Session II. Side-Effects of Topical Corticosteroid Therapy Dermatologica 152 (Suppl. 1): 107 115 (1976)
Steroid Atrophy - A Histological Appraisal E. W il s o n J o n e s 1 The Institute of Dermatology, London
Key Words. Atrophy ■Corticosteroids • Histopathology Abstract. The histological changes induced by 1 month's applications of various corti costeroids to normal forearm skin were studied. Marked epidermal atrophy was present at 1 month with the more potent steroids, but the dermal changes were minimal or absent. The methods outlined in this study could serve as a useful model for assessing the unwanted atrophogenic action of potent corticosteroid preparations.
1 My thanks are due to Mr. E. A. W heeler for expert histological assistance and to Gist-Brocades for supplying volunteers and corticosteroid preparations.
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It would be trite to comment that the discovery of the original anti-inflammatory surface active steroids has transformed much of der matological treatment with immense benefit to patients. However, the introduction of the relatively cheap, even more powerful fluorinated corticosteroids, unless used judiciously, has been at the price of unwanted short and long-term complications. Other authors in this symposium have discussed the clinical complications of striae and skin atrophy, potentiation and masking of skin infections and the aggravation of rosacea and other facial dermatoses. The mechanisms of steroid action on the skin are complex [3] and much work is required to unravel the details of their cellular effects [1,8]. Table I summarizes some of the most important actions of the anti-inflammatory steroids on the skin and poses what is to me the key problem of cutaneous steroid therapeutics. The ultimate, the panacea would be the advent of a powerful anti-inflammatory steroid which did not suppress protein synthesis and cause atrophy.
108
W ilson J ones
Table I. Some of the more important actions of steroids on the skin
Mitotic inhibition is one of the pathways [2] by which steroids act but this action may be both beneficial and harmful. Thus, mitotic inhibition may be one of the mechanisms by which the local recruitment of inflamma tory cells is suppressed, but on the other hand, inhibition of fibroblasts may in part determine dermal atrophy. The antimitotic action on the epidermis may be a particularly valuable action of steroids in the treatment of psoriasis due to suppression of epidermopoesis. At present a considerable bar to progress in developing new steroids is the lack of any satisfactory model by which the unwanted atrophogenic effects of the anti-inflammatory steroids can be assessed. It is known that the clinical changes of steroid-induced atrophy go hand in hand with evidence of histological atrophy. Figure 1 illustrates the histological changes in a biopsy of the thigh of a woman aged 42 with striae who had been using large quantities of potent fluorinated steroid ointments for several years for psoriasis. The points to note are the marked reduction of the total thickness of the dermis which results in the close proximity of the sweat glands and the fat to the surface. The dermal thinning is almost entirely due to wasting of the collagen bundles while conversely the unaffect ed elastica fibres appear crowded together due to the concertina-like collapse of the dermis (fig. 2). It has been our concern to develop an experimental model for assessing steroid atrophy in human subjects. Devising experiments is subject to two main limitations: (1) the difficulty of producing a significant degree of atrophy within a reasonably short period of time, and (2) the measurement of dermal thickness in histological specimens. It has to be appreciated that the depth of the dermis varies considerably according to the exact site, the age and the sex of the subject [6], Sun-exposure and elastosis introduces a complicating factor that cannot be entirely eliminated by using the internal
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
Suppression of inflammation Due to lymphocyte inhibition? Stabilizes lysosomes? Inhibition of protein synthesis Causing atrophy? Mitotic inhibition Causing atrophy and suppression of inflammatory cells?
The Atrophogenic Effects of Corticosteroids
109
Fig. 1. Biopsy of thigh showing dermal atrophy due to the prolonged application of potent corticosteroids. HE. x 25.
aspect of the forearms. The lower border of the dermis is not clearly defined and additional factors are the technical problems of the vertical orientation of small punch biopsies and the variable effects of fixation on different tissues. It is difficult with a good ethical conscience to remove really large specimens from volunteers in sufficient numbers to eliminate some of the factors outlined here.
The normal forearm skin of 9 adult male volunteers between the ages of 22 and 45 was used. Steroid and ointment base preparations were applied daily under polythene occlusion to marked areas on the flexor aspect of the forearm for 1 month. Each preparation was applied in a double-blind randomized fashion so that neither subject nor investigator knew the identity of the compound. The compounds used were: ( I) betamethasone 17-valerate (0.1 %) ointm ent; (2) hydrocortisone 17-butyrate (commercially available ‘Locoid’) ointment; (3) hydrocortisone 1% ointment, and (4) Locoid ointment base without steroid. A 4-mm control punch biopsy was taken from an adjacent site immediately before starting the steroid applications. 4-mm punch biopsies were taken from each o f the marked sites at the end of 1 month's treatment. The fresh specimens were fixed in normal saline and 5 pm paraffin-embedded sections were prepared and stained with haemotoxylin and eosin and with orcein for elastica. Representative sections were also stained with PAS and Alcian blue.
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
Methods
110
W ilson J ones
Fig. 2. Biopsy of thigh illustrating marked steroid atrophy. Note the crowding together of clastica fibres resulting from dermal collapse. Orcein lightly countcrstained with HE. x 100.
It was straight away apparent that dermal atrophy was almost inappre ciable histologically alter 1 month’s treatment with the various compounds, even though one or two of the application sites appeared erythematous and somewhat atrophic. In contrast to the absence of dermal changes there was marked epidermal atrophy at the sites corresponding to the applications of the 'potent' corticosteroids. The epidermal atrophy was assessed by:
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
Results
The Atrophogenic Effects of Corticosteroids
111
Fin. 3- A moderate degree of epidermal thinning following application of a potent corti costeroid to normal forearm skin. HE. x63.
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
(1) an arbitrary 3-point scale (1 normal, 2 moderate, and 3 marked atrophy), and (2) by counting the number of viable epidermal cells from the basal cell layer to the lower border of stratum corneum at ten random sites (from these counts a figure for the mean epidermal thickness was derived; an analysis of these findings and their statistical significance is reported by Dr. Marks elsewhere in this symposium). In essence, betamethasone 17-valerate applications caused the greatest degree of epidermal atrophy, hydrocortisone 17-butyrate a lesser degree of atrophy and hydrocortisone the least degree of atrophy. Figure 3 illustrates a specimen assessed as showing a moderate degree of epidermal atrophy. The Malpighian layer is reduced to approximately two thirds to half of the normal thickness. Reduced cell number and cell size and flattening of the rete ridges are the contributory factors. No obvious changes are present in the papillary connective tissue or in the vasculature. Figure 4 shows a biopsy with a marked degree of epidermal atrophy. Here the epidermis is grossly flattened and no rete ridges are apparent. In some specimens a resemblance to rodent epidermis was striking. The epidermis is reduced to between 2 and 4 cells in thickness and the individual
112
W ilson J ones
cells appear shrunken with a reduced cytoplasmic content (fig. 5). The basal cells are cuboidal rather than columnar. Many of their nuclei appear hyperchromatic as compared with adjacent Malpighian cells above suggesting such cells are blocked in the premitotic DNA synthesis stage of the cell cycle. In several of the specimens showing a marked degree of epidermal atrophy, glycogen accumulation (PAS/Alcian blue staining with and without diastase control) was notable in the upper Malpighian and granular cell layers (fig. 6). The glycogen deposits occurred as coarse peri nuclear granules. In specimens assessed as normal or showing only a moderate degree of atrophy, glycogen was minimal (fine dust-like deposits) or absent. In a few of the specimens showing marked epidermal atrophy, the papillary connective tissue appeared somewhat attenuated but no obvious changes were present in the elastica pattern.
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
Fig. 4. Marked epidermal thinning due to potent corticosteroids, forearm skin. HE. x 40.
The Atrophogenic Effects of Corticosteroids
113
Fig. 6. Same specimen as illustrated in figure 4. PAS counterstained with Alcian blue, x 63.
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
>r.
Fig. 5. Detail o f epidermis illustrated in figure 4. HE. x400.
114
W ilson J ones
Discussion
In this study we have tried to determine whether it is practical to use human subjects as models for assessing steroid atrophy from topical applications by histological means. The disappointing aspect of our study was that even in the presence of profound epidermal atrophy the elastica dermal network was essentially unaltered indicating that collagen atrophy was absent or slight after 1 month’s exposure to surface steroids. This is not to say that there are no changes in the dermis at one month, but that conventional histology does not reveal them. In fact my collaborator Dr. M a r k s has produced evidence, using a radiological technique, that corticosteroids may induce a degree of dermal atrophy after short periods of steroid applications [4,5]. It is likely that in human subjects epidermal thinning is a first step in a sequence of changes that result in dermal atrophy, and that the thinned epidermis subsequently allows a far greater penetration of steroids into the dermis. Potent steroids if applied for several months to normal skin can cause marked atrophy, telangiectasia and scarring [7], but there are con siderable objections in submitting patients or volunteers to such experiments if simpler techniques can be devised. More studies are required to determine whether epidermal atrophy, of itself alone, could be used as a marker of steroid atrophy. If this should be so and the dermal changes follow in step with those of the epidermis, then the methods used here would be of great value in assessing the atrophogenic action of locally applied steroids.
1 Baxter. J. D. and F orsham . P. H.: Tissue effects of glucocorticoids. Am. J. Med. 53: 573-589 (1972). 2 F isher. L. B. and M aibach , H. I .: The effect of corticosteroids on human epidermal mitotic activity. Archs Derm. 103: 39 44 (1971). 3 Lee, S. S. and R app , Y .: The modern topical steroid. Int. J. Derm. /-/.■ 412 421 (1975). 4 M arks, R . : Methods for the assessment of skin atrophogenicity of topical corticosteroids. Dermatológica 152: suppl. 1, pp. 117 126 (Karger, Basel 1976). 5 M arks, R.; D ykes. P. J., and R oberts, H.: The measurement of corticosteroid induced dermal atrophy by a radiological method. Archs Derm. Res. 253: 93-96 (1975). 6 Shuster , S. and Bottoms, E . : Senile degeneration of skin collagen. Clin. Sci. 25: 487-491 (1963). 7 Stevanovic, D. V.: Corticosteroid-induced atrophy of the skin with telangiectasia, a clinical and experimental study. Br. J. Derm. S7: 548-556 (1972).
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
References
The Atrophogcnic Effects of Corticosteroids
115
8 Z urier , R. B. and W eissmann, G . : Anti-im m unologic and anti-inflam m atory effects o f steroid therapy. Med. Clins N. Am. 57: 1295 1307 (1975).
Discussion Sarkany : After 4 weeks of application of betamethasone 17-valerate, obvious dermal changes did occur, but the framework of the elastica in the dermis appeared to be preserved. May I suggest that the framework of the elastica might remain preserved even after more prolonged application of these fluorinated steroids, and that this is the reason why regeneration of the collagen takes place at a subsequent stage. In diseased skin where atrophy takes place no such elastica framework maintenance can be demonstrated, and therefore no regeneration is possible.
Prof. Dr. E. W ilson Jones, The Institute of Dermatology, Lisle Street, London WC2H 7BJ (Great Britain)
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
W ilson J ones : I think this might well be true. In striae where the elastic tissues become completely disrupted, no recovery is possible. The striae remain. I feel that probably although the collagen does waste in dermal atrophy, perhaps enough of it remains to serve as a guide-line.
Steroid Atrophy - A Histological Appraisal E. W il s o n J o n e s 1 The Institute of Dermatology, London
Key Words. Atrophy ■Corticosteroids • Histopathology Abstract. The histological changes induced by 1 month's applications of various corti costeroids to normal forearm skin were studied. Marked epidermal atrophy was present at 1 month with the more potent steroids, but the dermal changes were minimal or absent. The methods outlined in this study could serve as a useful model for assessing the unwanted atrophogenic action of potent corticosteroid preparations.
1 My thanks are due to Mr. E. A. W heeler for expert histological assistance and to Gist-Brocades for supplying volunteers and corticosteroid preparations.
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
It would be trite to comment that the discovery of the original anti-inflammatory surface active steroids has transformed much of der matological treatment with immense benefit to patients. However, the introduction of the relatively cheap, even more powerful fluorinated corticosteroids, unless used judiciously, has been at the price of unwanted short and long-term complications. Other authors in this symposium have discussed the clinical complications of striae and skin atrophy, potentiation and masking of skin infections and the aggravation of rosacea and other facial dermatoses. The mechanisms of steroid action on the skin are complex [3] and much work is required to unravel the details of their cellular effects [1,8]. Table I summarizes some of the most important actions of the anti-inflammatory steroids on the skin and poses what is to me the key problem of cutaneous steroid therapeutics. The ultimate, the panacea would be the advent of a powerful anti-inflammatory steroid which did not suppress protein synthesis and cause atrophy.
108
W ilson J ones
Table I. Some of the more important actions of steroids on the skin
Mitotic inhibition is one of the pathways [2] by which steroids act but this action may be both beneficial and harmful. Thus, mitotic inhibition may be one of the mechanisms by which the local recruitment of inflamma tory cells is suppressed, but on the other hand, inhibition of fibroblasts may in part determine dermal atrophy. The antimitotic action on the epidermis may be a particularly valuable action of steroids in the treatment of psoriasis due to suppression of epidermopoesis. At present a considerable bar to progress in developing new steroids is the lack of any satisfactory model by which the unwanted atrophogenic effects of the anti-inflammatory steroids can be assessed. It is known that the clinical changes of steroid-induced atrophy go hand in hand with evidence of histological atrophy. Figure 1 illustrates the histological changes in a biopsy of the thigh of a woman aged 42 with striae who had been using large quantities of potent fluorinated steroid ointments for several years for psoriasis. The points to note are the marked reduction of the total thickness of the dermis which results in the close proximity of the sweat glands and the fat to the surface. The dermal thinning is almost entirely due to wasting of the collagen bundles while conversely the unaffect ed elastica fibres appear crowded together due to the concertina-like collapse of the dermis (fig. 2). It has been our concern to develop an experimental model for assessing steroid atrophy in human subjects. Devising experiments is subject to two main limitations: (1) the difficulty of producing a significant degree of atrophy within a reasonably short period of time, and (2) the measurement of dermal thickness in histological specimens. It has to be appreciated that the depth of the dermis varies considerably according to the exact site, the age and the sex of the subject [6], Sun-exposure and elastosis introduces a complicating factor that cannot be entirely eliminated by using the internal
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
Suppression of inflammation Due to lymphocyte inhibition? Stabilizes lysosomes? Inhibition of protein synthesis Causing atrophy? Mitotic inhibition Causing atrophy and suppression of inflammatory cells?
The Atrophogenic Effects of Corticosteroids
109
Fig. 1. Biopsy of thigh showing dermal atrophy due to the prolonged application of potent corticosteroids. HE. x 25.
aspect of the forearms. The lower border of the dermis is not clearly defined and additional factors are the technical problems of the vertical orientation of small punch biopsies and the variable effects of fixation on different tissues. It is difficult with a good ethical conscience to remove really large specimens from volunteers in sufficient numbers to eliminate some of the factors outlined here.
The normal forearm skin of 9 adult male volunteers between the ages of 22 and 45 was used. Steroid and ointment base preparations were applied daily under polythene occlusion to marked areas on the flexor aspect of the forearm for 1 month. Each preparation was applied in a double-blind randomized fashion so that neither subject nor investigator knew the identity of the compound. The compounds used were: ( I) betamethasone 17-valerate (0.1 %) ointm ent; (2) hydrocortisone 17-butyrate (commercially available ‘Locoid’) ointment; (3) hydrocortisone 1% ointment, and (4) Locoid ointment base without steroid. A 4-mm control punch biopsy was taken from an adjacent site immediately before starting the steroid applications. 4-mm punch biopsies were taken from each o f the marked sites at the end of 1 month's treatment. The fresh specimens were fixed in normal saline and 5 pm paraffin-embedded sections were prepared and stained with haemotoxylin and eosin and with orcein for elastica. Representative sections were also stained with PAS and Alcian blue.
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
Methods
110
W ilson J ones
Fig. 2. Biopsy of thigh illustrating marked steroid atrophy. Note the crowding together of clastica fibres resulting from dermal collapse. Orcein lightly countcrstained with HE. x 100.
It was straight away apparent that dermal atrophy was almost inappre ciable histologically alter 1 month’s treatment with the various compounds, even though one or two of the application sites appeared erythematous and somewhat atrophic. In contrast to the absence of dermal changes there was marked epidermal atrophy at the sites corresponding to the applications of the 'potent' corticosteroids. The epidermal atrophy was assessed by:
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
Results
The Atrophogenic Effects of Corticosteroids
111
Fin. 3- A moderate degree of epidermal thinning following application of a potent corti costeroid to normal forearm skin. HE. x63.
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
(1) an arbitrary 3-point scale (1 normal, 2 moderate, and 3 marked atrophy), and (2) by counting the number of viable epidermal cells from the basal cell layer to the lower border of stratum corneum at ten random sites (from these counts a figure for the mean epidermal thickness was derived; an analysis of these findings and their statistical significance is reported by Dr. Marks elsewhere in this symposium). In essence, betamethasone 17-valerate applications caused the greatest degree of epidermal atrophy, hydrocortisone 17-butyrate a lesser degree of atrophy and hydrocortisone the least degree of atrophy. Figure 3 illustrates a specimen assessed as showing a moderate degree of epidermal atrophy. The Malpighian layer is reduced to approximately two thirds to half of the normal thickness. Reduced cell number and cell size and flattening of the rete ridges are the contributory factors. No obvious changes are present in the papillary connective tissue or in the vasculature. Figure 4 shows a biopsy with a marked degree of epidermal atrophy. Here the epidermis is grossly flattened and no rete ridges are apparent. In some specimens a resemblance to rodent epidermis was striking. The epidermis is reduced to between 2 and 4 cells in thickness and the individual
112
W ilson J ones
cells appear shrunken with a reduced cytoplasmic content (fig. 5). The basal cells are cuboidal rather than columnar. Many of their nuclei appear hyperchromatic as compared with adjacent Malpighian cells above suggesting such cells are blocked in the premitotic DNA synthesis stage of the cell cycle. In several of the specimens showing a marked degree of epidermal atrophy, glycogen accumulation (PAS/Alcian blue staining with and without diastase control) was notable in the upper Malpighian and granular cell layers (fig. 6). The glycogen deposits occurred as coarse peri nuclear granules. In specimens assessed as normal or showing only a moderate degree of atrophy, glycogen was minimal (fine dust-like deposits) or absent. In a few of the specimens showing marked epidermal atrophy, the papillary connective tissue appeared somewhat attenuated but no obvious changes were present in the elastica pattern.
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
Fig. 4. Marked epidermal thinning due to potent corticosteroids, forearm skin. HE. x 40.
The Atrophogenic Effects of Corticosteroids
113
Fig. 6. Same specimen as illustrated in figure 4. PAS counterstained with Alcian blue, x 63.
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
>r.
Fig. 5. Detail o f epidermis illustrated in figure 4. HE. x400.
114
W ilson J ones
Discussion
In this study we have tried to determine whether it is practical to use human subjects as models for assessing steroid atrophy from topical applications by histological means. The disappointing aspect of our study was that even in the presence of profound epidermal atrophy the elastica dermal network was essentially unaltered indicating that collagen atrophy was absent or slight after 1 month’s exposure to surface steroids. This is not to say that there are no changes in the dermis at one month, but that conventional histology does not reveal them. In fact my collaborator Dr. M a r k s has produced evidence, using a radiological technique, that corticosteroids may induce a degree of dermal atrophy after short periods of steroid applications [4,5]. It is likely that in human subjects epidermal thinning is a first step in a sequence of changes that result in dermal atrophy, and that the thinned epidermis subsequently allows a far greater penetration of steroids into the dermis. Potent steroids if applied for several months to normal skin can cause marked atrophy, telangiectasia and scarring [7], but there are con siderable objections in submitting patients or volunteers to such experiments if simpler techniques can be devised. More studies are required to determine whether epidermal atrophy, of itself alone, could be used as a marker of steroid atrophy. If this should be so and the dermal changes follow in step with those of the epidermis, then the methods used here would be of great value in assessing the atrophogenic action of locally applied steroids.
1 Baxter. J. D. and F orsham . P. H.: Tissue effects of glucocorticoids. Am. J. Med. 53: 573-589 (1972). 2 F isher. L. B. and M aibach , H. I .: The effect of corticosteroids on human epidermal mitotic activity. Archs Derm. 103: 39 44 (1971). 3 Lee, S. S. and R app , Y .: The modern topical steroid. Int. J. Derm. /-/.■ 412 421 (1975). 4 M arks, R . : Methods for the assessment of skin atrophogenicity of topical corticosteroids. Dermatológica 152: suppl. 1, pp. 117 126 (Karger, Basel 1976). 5 M arks, R.; D ykes. P. J., and R oberts, H.: The measurement of corticosteroid induced dermal atrophy by a radiological method. Archs Derm. Res. 253: 93-96 (1975). 6 Shuster , S. and Bottoms, E . : Senile degeneration of skin collagen. Clin. Sci. 25: 487-491 (1963). 7 Stevanovic, D. V.: Corticosteroid-induced atrophy of the skin with telangiectasia, a clinical and experimental study. Br. J. Derm. S7: 548-556 (1972).
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
References
The Atrophogcnic Effects of Corticosteroids
115
8 Z urier , R. B. and W eissmann, G . : Anti-im m unologic and anti-inflam m atory effects o f steroid therapy. Med. Clins N. Am. 57: 1295 1307 (1975).
Discussion Sarkany : After 4 weeks of application of betamethasone 17-valerate, obvious dermal changes did occur, but the framework of the elastica in the dermis appeared to be preserved. May I suggest that the framework of the elastica might remain preserved even after more prolonged application of these fluorinated steroids, and that this is the reason why regeneration of the collagen takes place at a subsequent stage. In diseased skin where atrophy takes place no such elastica framework maintenance can be demonstrated, and therefore no regeneration is possible.
Prof. Dr. E. W ilson Jones, The Institute of Dermatology, Lisle Street, London WC2H 7BJ (Great Britain)
Downloaded by: King's College London 137.73.144.138 - 5/24/2018 11:35:48 PM
W ilson J ones : I think this might well be true. In striae where the elastic tissues become completely disrupted, no recovery is possible. The striae remain. I feel that probably although the collagen does waste in dermal atrophy, perhaps enough of it remains to serve as a guide-line.
