Side effect transparency: Ethical issues when prescribing systemic steroids
Authors: Qiang Zhang, Jane M. Grant-Kels
Journal: Journal of the American Academy of Dermatology (2024)

Dr Dermatoethicist: I prescribed a 3-week course of tapering systemic steroids for a patient with widespread poison ivy. How many potential side effects are we ethically required to inform the patient of?—Concerned Dermatologist Dr Dermatoethicist: I prescribed a 3-week course of tapering systemic steroids for a patient with widespread poison ivy. How many potential side effects are we ethically required to inform the patient of? —Concerned Dermatologist Dear Concerned Dermatologist: The many side effects of systemic steroids (including skin atrophy, striae, telangiectasia, acneiform eruption, arrhythmias, hypothalamic-pituitary-adrenal suppression, diabetes, hypertension, glaucoma, femoral head necrosis, increased rates of sepsis, venous thromboembolism, and fracture, among others) limits the use of this efficacious medication, especially long-term.1Rathod S.S. Motghare V.M. Deshmukh V.S. et al.Prescribing practices of topical corticosteroids in the outpatient dermatology department of a rural tertiary care teaching hospital.Indian J Dermatol. 2013; 58: 342-345Crossref Scopus (23) Google Scholar,2Waljee A.K. Rogers M.A. Lin P. et al.Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study.BMJ. 2017; 357: j1415Crossref PubMed Scopus (520) Google Scholar Even relatively short-term use of systemic steroids can have negative sequalae. One study demonstrated that within 30 days of initiating 20 mg/d or less of oral corticosteroids increased the risk of sepsis, thromboembolism, and fractures for up to 90 days.2Waljee A.K. Rogers M.A. Lin P. et al.Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study.BMJ. 2017; 357: j1415Crossref PubMed Scopus (520) Google Scholar When prescribing systemic steroids even for contact dermatitis, the ethical principles of truthfulness, autonomy, beneficence, and nonmaleficence are at play. Respect for truthfulness or informed consent protects a patient's right to information and requires us to never intentionally withhold information from patients or lie or deceive patients about their condition and recommended treatments.3Edwin A. Don't lie but don't tell the whole truth: the therapeutic privilege - is it ever justified?.Ghana Med J. 2008; 42: 156-161Google Scholar Although treating poison ivy usually involves an add-on patient, the patient has a right to know about the potential side effects of oral steroids, even for a 3-week course. Patient autonomy is often in conflict with paternalism, the concept that the physician "knows best" and makes decisions based on what they think is in the patient's best interests without consulting or partnering with the patient. This could involve intentionally withholding information from patients about side effects so that the physician can relieve the patient's acute discomfort efficiently and without causing the patient undue worry. However, paternalism should be avoided and the patient's right to autonomy or control over their medical care should be respected. Beneficence mandates that it is the obligation of the physician to benefit and promote their patient's welfare.4Varkey B. Principles of clinical ethics and their application to practice.Med Princ Pract. 2021; 30: 17-28Crossref PubMed Scopus (202) Google Scholar Therefore it is your obligation to try and relieve your patient's discomfort from their rash but also to inform them of potential side effects, especially those that may be more relevant to their medical history (such as a past medical history of osteoporosis or diabetes). This affords the patient the right to play a role in their therapeutic decision. Because of documented reports of serious side effects, such as osteonecrosis of the femoral head resulting from even a short course of a moderate dose of corticosteroids in relatively young patients, patients need to be made aware of the risks of therapy.5McKee M.D. Waddell J.P. Kudo P.A. et al.Osteonecrosis of the femoral head in men following short-course corticosteroid therapy: a report of 15 cases.CMAJ. 2001; 164: 205-206Google Scholar Nonmaleficence, our obligation to not harm the patient, mandates that we have an obligation to relieve patients of their suffering.4Varkey B. Principles of clinical ethics and their application to practice.Med Princ Pract. 2021; 30: 17-28Crossref PubMed Scopus (202) Google Scholar Therefore, although steroids are efficacious, we need to discuss the potential side effects despite having other patients waiting to be seen. If the patient prefers alternative therapies, we should inform them of the pros and cons of these therapies compared to the systemic steroid course. Even though informing patients of the potential side effects of systemic steroids is time-consuming, patients prescribed systemic steroids, even short-term, need to understand the risks, benefits, and proper usage of these medications. —Dr Dermatoethicist None disclosed.