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Corticosteroid
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<h2 id="classes">Classes</h2> <ul><li><a href="/facts/Glucocorticoid/2P91Aj3S">Glucocorticoids</a> such as <a href="/facts/Cortisol/5IvRV0cm">cortisol</a> affect carbohydrate, fat, and protein metabolism, and have <a href="/facts/Anti-inflammatory/W27poSUd">anti-inflammatory</a>, <a href="/facts/Immunosuppression/22GHUHkr">immunosuppressive</a>, <a href="/facts/Chemotherapy/fWTLbaUT">anti-proliferative</a>, and <a href="/facts/Vasoconstriction/9hdY0aR2">vasoconstrictive</a> effects.<a class="footnote-ref" id="fnref:3" href="#fn:3"><sup>3</sup></a> Anti-inflammatory effects are mediated by blocking the action of <a href="/facts/Inflammation/Ura86MIy">inflammatory mediators</a> (<a href="/facts/Transrepression/IVvaDIYa">transrepression</a>) and inducing anti-inflammatory mediators (<a href="/facts/Transactivation/L5cuFGwq">transactivation</a>).<a class="footnote-ref" id="fnref:4" href="#fn:4"><sup>4</sup></a> Immunosuppressive effects are mediated by suppressing <a href="/facts/Type_IV_hypersensitivity/yftfcJR5">delayed hypersensitivity reactions</a> by direct action on <a href="/facts/T_cell/5z6PQ9UN">T-lymphocytes</a>.<a class="footnote-ref" id="fnref:5" href="#fn:5"><sup>5</sup></a> Anti-proliferative effects are mediated by inhibition of <a href="/facts/DNA_synthesis/ywV1plto">DNA synthesis</a> and <a href="/facts/Epidermis/JvRABubP">epidermal cell</a> turnover.<a class="footnote-ref" id="fnref:6" href="#fn:6"><sup>6</sup></a> <a href="/facts/Vasoconstriction/9hdY0aR2">Vasoconstrictive</a> effects are mediated by inhibiting the action of inflammatory mediators such as <a href="/facts/Histamine/Vfjda665">histamine</a>.<a class="footnote-ref" id="fnref:7" href="#fn:7"><sup>7</sup></a></li> <li><a href="/facts/Mineralocorticoid/Ruj1B1Mv">Mineralocorticoids</a> such as <a href="/facts/Aldosterone/tjw4dr1u">aldosterone</a> are primarily involved in the regulation of <a href="/facts/Water-electrolyte_balance/zXEhVwD4">electrolyte</a> and water balance by modulating <a href="/facts/Ion_transporter/x41gIvhr">ion transport</a> in the <a href="/facts/Epithelium/ecKHcHC3">epithelial cells</a> of the <a href="/facts/Nephron/ss24U1zW">renal tubules</a> of the <a href="/facts/Kidney/HBspPrv9">kidney</a>.<a class="footnote-ref" id="fnref:8" href="#fn:8"><sup>8</sup></a></li></ul> <h2 id="medical-uses">Medical uses</h2> <p>Synthetic <a href="/facts/Pharmaceutical_drug/h9mhwWP2">pharmaceutical drugs</a> with corticosteroid-like effects are used in a variety of conditions, ranging from <a href="/facts/Hematological_cancer/tzyyShka">hematological neoplasms</a><a class="footnote-ref" id="fnref:9" href="#fn:9"><sup>9</sup></a> to <a href="/facts/Brain_tumor/avjI5Nhm">brain tumors</a> or <a href="/facts/Skin_disease/Vkr5XpeG">skin diseases</a>. <a href="/facts/Dexamethasone/rwAhDqls">Dexamethasone</a> and its derivatives are almost pure glucocorticoids, while <a href="/facts/Prednisone/eGgPIauI">prednisone</a> and its derivatives have some mineralocorticoid action in addition to the glucocorticoid effect. <a href="/facts/Fludrocortisone/BpDJfgJd">Fludrocortisone</a> (Florinef) is a synthetic mineralocorticoid. <a href="/facts/Hydrocortisone/zvRCrYXG">Hydrocortisone</a> (cortisol) is typically used for replacement therapy, <i>e.g.</i> for <a href="/facts/Adrenal_insufficiency/7oxdJtF4">adrenal insufficiency</a> and <a href="/facts/Congenital_adrenal_hyperplasia/HTXWkLl8">congenital adrenal hyperplasia</a>. </p><p>Medical conditions treated with systemic corticosteroids:<a class="footnote-ref" id="fnref:10" href="#fn:10"><sup>10</sup></a><a class="footnote-ref" id="fnref:11" href="#fn:11"><sup>11</sup></a> </p> <ul><li><a href="/facts/Allergy/dYAVosh8">Allergy</a> and <a href="/facts/Pulmonology/k0hUHBhu">respirology</a> medicine <ul><li><a href="/facts/Asthma/7GkJvxn3">Asthma</a> (severe exacerbations)</li> <li><a href="/facts/Chronic_obstructive_pulmonary_disease/ud3oXGCr">Chronic obstructive pulmonary disease</a> (COPD)</li> <li><a href="/facts/Allergic_rhinitis/ukE6bkIs">Allergic rhinitis</a></li> <li><a href="/facts/Atopic_dermatitis/DvmdVwWu">Atopic dermatitis</a></li> <li><a href="/facts/Hives/zMkVo9qL">Hives</a></li> <li><a href="/facts/Angioedema/Wpc7qnTK">Angioedema</a></li> <li><a href="/facts/Anaphylaxis/F9IDQxeL">Anaphylaxis</a></li> <li><a href="/facts/Food_allergy/Nkf1e70o">Food allergies</a></li> <li><a href="/facts/Drug_allergy/FI5aRqvs">Drug allergies</a></li> <li><a href="/facts/Nasal_polyp/scc2WAU1">Nasal polyps</a></li> <li><a href="/facts/Hypersensitivity_pneumonitis/esRClIqB">Hypersensitivity pneumonitis</a></li> <li><a href="/facts/Sarcoidosis/qgV7Uoe8">Sarcoidosis</a></li> <li><a href="/facts/Eosinophilic_pneumonia/N3AVf5S7">Eosinophilic pneumonia</a></li> <li>Some other types of <a href="/facts/Pneumonia/Jw0KquTA">pneumonia</a> (in addition to the traditional <a href="/facts/Antibiotic/sF1kIfxg">antibiotic</a> treatment protocols)</li> <li><a href="/facts/Interstitial_lung_disease/0LQEwsGc">Interstitial lung disease</a></li></ul></li> <li><a href="/facts/Dermatology/YfvJ8uXn">Dermatology</a> <ul><li><a href="/facts/Pemphigus_vulgaris/nV6IcNNz">Pemphigus vulgaris</a></li> <li><a href="/facts/Contact_dermatitis/Xm6PEgcw">Contact dermatitis</a></li></ul></li> <li><a href="/facts/Endocrinology/4SqQu1NN">Endocrinology</a> (usually at physiologic doses) <ul><li><a href="/facts/Addison%27s_disease/Lp8AqjEX">Addison's disease</a></li> <li><a href="/facts/Adrenal_insufficiency/7oxdJtF4">Adrenal insufficiency</a></li> <li><a href="/facts/Congenital_adrenal_hyperplasia/HTXWkLl8">Congenital adrenal hyperplasia</a></li></ul></li> <li><a href="/facts/Gastroenterology/89aMlDF0">Gastroenterology</a> <ul><li><a href="/facts/Ulcerative_colitis/BIkyFzRj">Ulcerative colitis</a></li> <li><a href="/facts/Crohn%27s_disease/zm55cBtd">Crohn's disease</a></li> <li><a href="/facts/Autoimmune_hepatitis/aU7dC4Lc">Autoimmune hepatitis</a></li></ul></li> <li><a href="/facts/Hematology/DF6QqYQk">Hematology</a> <ul><li><a href="/facts/Lymphoma/418wcMEl">Lymphoma</a></li> <li><a href="/facts/Leukemia/WpEfW0Qh">Leukemia</a></li> <li><a href="/facts/Hemolytic_anemia/qNz6wDct">Hemolytic anemia</a></li> <li><a href="/facts/Idiopathic_thrombocytopenic_purpura/lowYlK4Y">Idiopathic thrombocytopenic purpura</a></li> <li><a href="/facts/Multiple_Myeloma/Pp9Tt33l">Multiple Myeloma</a></li></ul></li> <li><a href="/facts/Rheumatology/sqYLJrLa">Rheumatology</a>/<a href="/facts/Immunology/vylm0L8e">Immunology</a> <ul><li><a href="/facts/Rheumatoid_arthritis/qFK4Xwv7">Rheumatoid arthritis</a></li> <li><a href="/facts/Systemic_lupus_erythematosus/kfHYawre">Systemic lupus erythematosus</a></li> <li><a href="/facts/Polymyalgia_rheumatica/xppFrdDH">Polymyalgia rheumatica</a></li> <li><a href="/facts/Polymyositis/T6bouQSf">Polymyositis</a></li> <li><a href="/facts/Dermatomyositis/VDJk2fE5">Dermatomyositis</a></li> <li><a href="/facts/Polyarteritis/RbFBUVKG">Polyarteritis</a></li> <li><a href="/facts/Vasculitis/rS2rP61A">Vasculitis</a></li></ul></li> <li><a href="/facts/Ophthalmology/024hdTWF">Ophthalmology</a> <ul><li><a href="/facts/Uveitis/le0Ns1eE">Uveitis</a></li> <li><a href="/facts/Optic_neuritis/Nhj3r878">Optic neuritis</a></li> <li><a href="/facts/Keratoconjunctivitis/9y06sSM4">Keratoconjunctivitis</a></li></ul></li> <li>Other conditions <ul><li><a href="/facts/Multiple_sclerosis/vghXl0IQ">Multiple sclerosis</a> relapses</li> <li><a href="/facts/Organ_transplantation/1jNvVJn6">Organ transplantation</a></li> <li><a href="/facts/Nephrotic_syndrome/YG7bUzWV">Nephrotic syndrome</a></li> <li><a href="/facts/Hepatitis/FIN87T5e">Chronic hepatitis</a> (<a href="/facts/Flareup/55eeQlGL">flare ups</a>)</li> <li><a href="/facts/Cerebral_edema/UDlqKHrV">Cerebral edema</a></li> <li><a href="/facts/IgG4-related_disease/LBpERebk">IgG4-related disease</a></li> <li><a href="/facts/Prostate_cancer/Mx7XuDhm">Prostate cancer</a></li> <li><a href="/facts/Tendinosis/ME5bVuKn">Tendinosis</a></li> <li><a href="/facts/Lichen_planus/R82WnXep">Lichen planus</a></li></ul></li></ul> <p>Topical formulations are also available for the <a href="/facts/Skin_disease/Vkr5XpeG">skin</a>, eyes (<a href="/facts/Uveitis/le0Ns1eE">uveitis</a>), lungs (<a href="/facts/Asthma/7GkJvxn3">asthma</a>), nose (<a href="/facts/Rhinitis/VYf2UR8U">rhinitis</a>), and <a href="/facts/Inflammatory_bowel_disease/RuxcPW5A">bowels</a>. Corticosteroids are also used supportively to prevent nausea, often in combination with 5-HT3 antagonists (e.g., <a href="/facts/Ondansetron/ovIEjwwL">ondansetron</a>). </p><p>Typical <a href="/facts/Adverse_drug_reaction/Ea0ktF6J">undesired effects</a> of glucocorticoids present quite uniformly as drug-induced <a href="/facts/Cushing%27s_syndrome/AYW7Gjma">Cushing's syndrome</a>. Typical mineralocorticoid side-effects are <a href="/facts/Arterial_hypertension/wlAvBfcf">hypertension</a> (abnormally high blood pressure), steroid induced diabetes mellitus, psychosis, poor sleep, <a href="/facts/Hypokalemia/XvS1S7s6">hypokalemia</a> (low potassium levels in the blood), <a href="/facts/Hypernatremia/IKu0CwLv">hypernatremia</a> (high sodium levels in the blood) without causing <a href="/facts/Peripheral_edema/7vfC7USH">peripheral edema</a>, <a href="/facts/Metabolic_alkalosis/M4KlT5b7">metabolic alkalosis</a> and connective tissue weakness.<a class="footnote-ref" id="fnref:12" href="#fn:12"><sup>12</sup></a> Wound healing or ulcer formation may be inhibited by the immunosuppressive effects. </p><p>A variety of steroid medications, from anti-allergy nasal sprays (<a href="/facts/Nasonex/ALWaB4xR">Nasonex</a>, <a href="/facts/Flonase/MfnCWC1x">Flonase</a>) to topical skin creams, to eye drops (<a href="/facts/Tobradex/88K9Bhku">Tobradex</a>), to prednisone have been implicated in the development of <a href="/facts/Central_serous_retinopathy/ye8WxXJD">central serous retinopathy</a> (CSR).<a class="footnote-ref" id="fnref:13" href="#fn:13"><sup>13</sup></a><a class="footnote-ref" id="fnref:14" href="#fn:14"><sup>14</sup></a> </p><p>Corticosteroids have been widely used in treating people with <a href="/facts/Traumatic_brain_injury/DTq110vw">traumatic brain injury</a>.<a class="footnote-ref" id="fnref:15" href="#fn:15"><sup>15</sup></a> A <a href="/facts/Systematic_review/dGvq3BGx">systematic review</a> identified 20 randomised controlled trials and included 12,303 participants, then compared patients who received corticosteroids with patients who received no treatment. The authors recommended people with traumatic head injury should not be routinely treated with corticosteroids.<a class="footnote-ref" id="fnref:16" href="#fn:16"><sup>16</sup></a> </p> <h2 id="pharmacology">Pharmacology</h2> <p>Corticosteroids act as <a href="/facts/Agonist/nz8U5NNp">agonists</a> of the <a href="/facts/Glucocorticoid_receptor/NUsGokjq">glucocorticoid receptor</a> and/or the <a href="/facts/Mineralocorticoid_receptor/kwNhKIyC">mineralocorticoid receptor</a>. </p><p>In addition to their corticosteroid activity, some corticosteroids may have some <a href="/facts/Progestogen_(medication)/8xMJYV3A">progestogenic</a> activity and may produce sex-related side effects.<a class="footnote-ref" id="fnref:17" href="#fn:17"><sup>17</sup></a><a class="footnote-ref" id="fnref:18" href="#fn:18"><sup>18</sup></a><a class="footnote-ref" id="fnref:19" href="#fn:19"><sup>19</sup></a><a class="footnote-ref" id="fnref:20" href="#fn:20"><sup>20</sup></a> </p> <h2 id="pharmacogenetics">Pharmacogenetics</h2> <h3>Asthma</h3> <p>Patients' response to inhaled corticosteroids has some basis in genetic variations. Two genes of interest are CHRH1 (<a href="/facts/Corticotropin-releasing_hormone_receptor_1/erbKdkDm">corticotropin-releasing hormone receptor 1</a>) and TBX21 (transcription factor T-bet). Both genes display some degree of polymorphic variation in humans, which may explain how some patients respond better to inhaled corticosteroid therapy than others.<a class="footnote-ref" id="fnref:21" href="#fn:21"><sup>21</sup></a><a class="footnote-ref" id="fnref:22" href="#fn:22"><sup>22</sup></a> However, not all asthma patients respond to corticosteroids and large sub groups of asthma patients are corticosteroid resistant.<a class="footnote-ref" id="fnref:23" href="#fn:23"><sup>23</sup></a> </p><p>A study funded by the Patient-Centered Outcomes Research Institute of children and teens with mild persistent asthma found that using the control inhaler as needed worked the same as daily use in improving asthma control, number of asthma flares, how well the lungs work, and quality of life. Children and teens using the inhaler as needed used about one-fourth the amount of corticosteroid medicine as children and teens using it daily.<a class="footnote-ref" id="fnref:24" href="#fn:24"><sup>24</sup></a><a class="footnote-ref" id="fnref:25" href="#fn:25"><sup>25</sup></a> </p> <h2 id="adverse-effects">Adverse effects</h2> <p>Use of corticosteroids has numerous side-effects, some of which may be severe: </p> <ul><li>Severe <a href="/facts/Amoebic_colitis/vMgDVDUf">amoebic colitis</a>: <a href="/facts/Fulminant/qIgEbAGW">Fulminant</a> amoebic colitis is associated with high case fatality and can occur in patients infected with the parasite <i><a href="/facts/Entamoeba_histolytica/lMPf2xDp">Entamoeba histolytica</a></i> after exposure to corticosteroid medications.<a class="footnote-ref" id="fnref:26" href="#fn:26"><sup>26</sup></a></li> <li>Neuropsychiatric: <a href="/facts/Steroid_psychosis/f9KAXfTF">steroid psychosis</a>,<a class="footnote-ref" id="fnref:27" href="#fn:27"><sup>27</sup></a> and <a href="/facts/Anxiety_(mood)/Geekl883">anxiety</a>,<a class="footnote-ref" id="fnref:28" href="#fn:28"><sup>28</sup></a> <a href="/facts/Depression_(mood)/GDNFWm1L">depression</a>. Therapeutic doses may cause a feeling of artificial well-being ("steroid euphoria").<a class="footnote-ref" id="fnref:29" href="#fn:29"><sup>29</sup></a> The neuropsychiatric effects are partly mediated by sensitization of the body to the actions of adrenaline. Therapeutically, the bulk of corticosteroid dose is given in the morning to mimic the body's diurnal rhythm; if given at night, the feeling of being energized will interfere with sleep. An extensive review is provided by Flores and Gumina.<a class="footnote-ref" id="fnref:30" href="#fn:30"><sup>30</sup></a></li> <li>Cardiovascular: Corticosteroids can cause sodium retention through a direct action on the kidney, in a manner analogous to the mineralocorticoid <a href="/facts/Aldosterone/tjw4dr1u">aldosterone</a>. This can result in fluid retention and <a href="/facts/Hypertension/wlAvBfcf">hypertension</a>.</li> <li>Metabolic: Corticosteroids cause a movement of body fat to the face and torso, resulting in "<a href="/facts/Moon_face/F3hpVY7V">moon face</a>", "buffalo hump", and "pot belly" or "beer belly", and cause movement of body fat away from the limbs. This has been termed <a href="/facts/Corticosteroid-induced_lipodystrophy/CrRQyejB">corticosteroid-induced lipodystrophy</a>. Due to the diversion of amino-acids to glucose, they are considered anti-anabolic, and long term therapy can cause muscle wasting (muscle atrophy).<a class="footnote-ref" id="fnref:31" href="#fn:31"><sup>31</sup></a> Besides muscle atrophy, steroid myopathy includes muscle pains (myalgias), muscle weakness (typically of the proximal muscles), serum creatine kinase normal, EMG myopathic, and some have type II (fast-twitch/glycolytic) fibre atrophy.<a class="footnote-ref" id="fnref:32" href="#fn:32"><sup>32</sup></a></li> <li>Endocrine: By increasing the production of glucose from amino-acid breakdown and opposing the action of insulin, corticosteroids can cause <a href="/facts/Hyperglycemia/HM8eNqfX">hyperglycemia</a>,<a class="footnote-ref" id="fnref:33" href="#fn:33"><sup>33</sup></a> <a href="/facts/Insulin_resistance/cz6oFqke">insulin resistance</a> and <a href="/facts/Diabetes_mellitus/2xeHXbsI">diabetes mellitus</a>.<a class="footnote-ref" id="fnref:34" href="#fn:34"><sup>34</sup></a></li> <li>Skeletal: <a href="/facts/Steroid-induced_osteoporosis/fpjUewe7">Steroid-induced osteoporosis</a> may be a side-effect of long-term corticosteroid use.<a class="footnote-ref" id="fnref:35" href="#fn:35"><sup>35</sup></a><a class="footnote-ref" id="fnref:36" href="#fn:36"><sup>36</sup></a><a class="footnote-ref" id="fnref:37" href="#fn:37"><sup>37</sup></a> Use of inhaled corticosteroids among children with asthma may result in decreased height.<a class="footnote-ref" id="fnref:38" href="#fn:38"><sup>38</sup></a></li> <li>Gastro-intestinal: While cases of <a href="/facts/Colitis/vMgDVDUf">colitis</a> have been reported, corticosteroids are often prescribed when the colitis, although due to suppression of the immune response to pathogens, should be considered only after ruling out infection or microbe/fungal overgrowth in the gastrointestinal tract. While the evidence for corticosteroids causing <a href="/facts/Peptic_ulcer/peMGnYCd">peptic ulceration</a> is relatively poor except for high doses taken for over a month,<a class="footnote-ref" id="fnref:39" href="#fn:39"><sup>39</sup></a> the majority of doctors as of 2010<a href="https://en.wikipedia.org/w/index.php?title=Corticosteroid&action=edit">[update]</a> still believe this is the case, and would consider protective prophylactic measures.<a class="footnote-ref" id="fnref:40" href="#fn:40"><sup>40</sup></a></li> <li>Eyes: chronic use may predispose to <a href="/facts/Cataract/RzN7k7K2">cataract</a> and <a href="/facts/Glaucoma/MWqWVNz3">glaucoma</a>. Clinical and experimental evidence indicates that corticosteroids can cause permanent eye damage by inducing central serous retinopathy (CSR, also known as central serous chorioretinopathy, CSC).<a class="footnote-ref" id="fnref:41" href="#fn:41"><sup>41</sup></a> This should be borne in mind when treating patients with <a href="/facts/Optic_neuritis/Nhj3r878">optic neuritis</a>. There is experimental and clinical evidence that, at least in <a href="/facts/Optic_neuritis/Nhj3r878">optic neuritis</a> speed of treatment initiation is important.<a class="footnote-ref" id="fnref:42" href="#fn:42"><sup>42</sup></a></li> <li>Vulnerability to infection: By suppressing immune reactions (which is one of the main reasons for their use in allergies), steroids may cause infections to flare up, notably <a href="/facts/Candidiasis/gklGEfuq">candidiasis</a>.<a class="footnote-ref" id="fnref:43" href="#fn:43"><sup>43</sup></a></li> <li>Pregnancy: Corticosteroids have a low but significant <a href="/facts/Teratogenic/j4BN6lsB">teratogenic</a> effect, causing a few birth defects per 1,000 pregnant women treated. Corticosteroids are therefore <a href="/facts/Contraindicated/HawhU8x9">contraindicated</a> in pregnancy.<a class="footnote-ref" id="fnref:44" href="#fn:44"><sup>44</sup></a></li> <li>Habituation: Topical steroid addiction (TSA) or <a href="/facts/Red_burning_skin/WxWQ6j9g">red burning skin</a> has been reported in long-term users of topical steroids (users who applied topical steroids to their skin over a period of weeks, months, or years).<a class="footnote-ref" id="fnref:45" href="#fn:45"><sup>45</sup></a><a class="footnote-ref" id="fnref:46" href="#fn:46"><sup>46</sup></a> TSA is characterised by uncontrollable, spreading dermatitis and worsening skin inflammation which requires a stronger topical steroid to get the same result as the first prescription. When topical steroid medication is lost, the skin experiences redness, burning, itching, hot skin, swelling, and/or oozing for a length of time. This is also called 'red skin syndrome' or 'topical steroid withdrawal' (TSW). After the withdrawal period is over the atopic dermatitis can cease or is less severe than it was before.<a class="footnote-ref" id="fnref:47" href="#fn:47"><sup>47</sup></a></li> <li>In children the short term use of steroids by mouth increases the risk of vomiting, behavioral changes, and sleeping problems.<a class="footnote-ref" id="fnref:48" href="#fn:48"><sup>48</sup></a></li> <li>Dysphonia: Inhaled corticosteroids are used for treatment of asthma as a standard treatment. This can cause local adverse effects like vocal cord dysfunction.<a class="footnote-ref" id="fnref:49" href="#fn:49"><sup>49</sup></a></li></ul> <h2 id="biosynthesis">Biosynthesis</h2> <p>The corticosteroids are synthesized from <a href="/facts/Cholesterol/TnfPlYc1">cholesterol</a> within the <a href="/facts/Adrenal_cortex/t4EkJgdy">adrenal cortex</a>.<a class="footnote-ref" id="fnref:50" href="#fn:50"><sup>50</sup></a> Most steroidogenic reactions are catalysed by <a href="/facts/Enzyme/DSI1Fh7y">enzymes</a> of the <a href="/facts/Cytochrome_P450/alxusFD0">cytochrome P450</a> family. They are located within the <a href="/facts/Mitochondria/ErHqrdJ1">mitochondria</a> and require <a href="/facts/Adrenodoxin/z0mdXhfb">adrenodoxin</a> as a cofactor (except <a href="/facts/21-hydroxylase/WUJ1b01V">21-hydroxylase</a> and <a href="/facts/17%CE%B1-hydroxylase/MQcrtxpv">17α-hydroxylase</a>). </p><p><a href="/facts/Aldosterone/tjw4dr1u">Aldosterone</a> and <a href="/facts/Corticosterone/rcMoEu7f">corticosterone</a> share the first part of their biosynthetic pathway. The last part is mediated either by the <a href="/facts/Aldosterone_synthase/qnPvyP3T">aldosterone synthase</a> (for <a href="/facts/Aldosterone/tjw4dr1u">aldosterone</a>) or by the <a href="/facts/11%CE%B2-hydroxylase/UNINEMj7">11β-hydroxylase</a> (for <a href="/facts/Corticosterone/rcMoEu7f">corticosterone</a>). These enzymes are nearly identical (they share 11β-hydroxylation and 18-hydroxylation functions), but aldosterone synthase is also able to perform an 18-oxidation. Moreover, aldosterone synthase is found within the <a href="/facts/Zona_glomerulosa/5WVzdq6P">zona glomerulosa</a> at the outer edge of the <a href="/facts/Adrenal_cortex/t4EkJgdy">adrenal cortex</a>; 11β-hydroxylase is found in the <a href="/facts/Zona_fasciculata/QGv1mbg8">zona fasciculata</a> and <a href="/facts/Zona_glomerulosa/5WVzdq6P">zona glomerulosa</a>. </p> <h2 id="classification">Classification</h2> <h3>By chemical structure</h3> <p>In general, corticosteroids are grouped into four classes, based on chemical structure. Allergic reactions to one member of a class typically indicate an intolerance of all members of the class. This is known as the "Coopman classification".<a class="footnote-ref" id="fnref:51" href="#fn:51"><sup>51</sup></a><a class="footnote-ref" id="fnref:52" href="#fn:52"><sup>52</sup></a> </p><p>The highlighted steroids are often used in the screening of allergies to topical steroids.<a class="footnote-ref" id="fnref:53" href="#fn:53"><sup>53</sup></a> </p> <h4>Group A – Hydrocortisone type</h4> <p><a href="/facts/Hydrocortisone/zvRCrYXG">Hydrocortisone</a>, <a href="/facts/Hydrocortisone_acetate/R6cIkhM3">hydrocortisone acetate</a>, <a href="/facts/Cortisone_acetate/X6KcxRL2">cortisone acetate</a>, <a href="/facts/Tixocortol_pivalate/75DlE4qk">tixocortol pivalate</a>, <a href="/facts/Prednisolone/aAB8cAPv">prednisolone</a>, <a href="/facts/Methylprednisolone/wzGSj2jQ">methylprednisolone</a>, and <a href="/facts/Prednisone/eGgPIauI">prednisone</a>. </p> <h4>Group B – Acetonides (and related substances)</h4> <p><a href="/facts/Amcinonide/xJc8qN87">Amcinonide</a>, <a href="/facts/Budesonide/4p8z8WBy">budesonide</a>, <a href="/facts/Desonide/GTBfYnJm">desonide</a>, <a href="/facts/Fluocinolone_acetonide/hv5RLYwX">fluocinolone acetonide</a>, <a href="/facts/Fluocinonide/KosLUAGl">fluocinonide</a>, <a href="/facts/Halcinonide/Eo96IBrh">halcinonide</a>, <a href="/facts/Triamcinolone_acetonide/8oe3CSR5">triamcinolone acetonide</a>, and <a href="/facts/Deflazacort/TEHtqnaC">Deflazacort</a> (O-isopropylidene derivative) </p> <h4>Group C – Betamethasone type</h4> <p><a href="/facts/Beclometasone/T0rSDyEx">Beclometasone</a>, <a href="/facts/Betamethasone/qM3DSjSR">betamethasone</a>, <a href="/facts/Dexamethasone/rwAhDqls">dexamethasone</a>, <a href="/facts/Fluocortolone/cSkS0HkU">fluocortolone</a>, <a href="/facts/Halometasone/y9vb3r3T">halometasone</a>, and <a href="/facts/Mometasone/ALWaB4xR">mometasone</a>. </p> <h4>Group D – Esters</h4> <h5>Group D1 – Halogenated (less labile)</h5> <p><a href="/facts/Alclometasone_dipropionate/p1mFt6xe">Alclometasone dipropionate</a>, <a href="/facts/Betamethasone_dipropionate/e2xSqCKE">betamethasone dipropionate</a>, <a href="/facts/Betamethasone_valerate/MbHDQy4o">betamethasone valerate</a>, <a href="/facts/Clobetasol_propionate/NQnltdL3">clobetasol propionate</a>, <a href="/facts/Clobetasone_butyrate/TUsY8uIk">clobetasone butyrate</a>, <a href="/facts/Fluprednidene_acetate/rvoVJ23a">fluprednidene acetate</a>, and <a href="/facts/Mometasone_furoate/ALWaB4xR">mometasone furoate</a>. </p> <h5>Group D2 – Labile prodrug esters</h5> <p><a href="/facts/Ciclesonide/Bpp4KQXb">Ciclesonide</a>, <a href="/facts/Cortisone_acetate/X6KcxRL2">cortisone acetate</a>, <a href="/facts/Hydrocortisone_aceponate/S17oaYrY">hydrocortisone aceponate</a>, <a href="/facts/Hydrocortisone_acetate/R6cIkhM3">hydrocortisone acetate</a>, <a href="/facts/Hydrocortisone_buteprate/shjdTRbL">hydrocortisone buteprate</a>, <a href="/facts/Hydrocortisone_butyrate/oAPw1CW9">hydrocortisone butyrate</a>, <a href="/facts/Hydrocortisone_valerate/gzyrMFyE">hydrocortisone valerate</a>, <a href="/facts/Prednicarbate/1nfCcXEa">prednicarbate</a>, and <a href="/facts/Tixocortol_pivalate/75DlE4qk">tixocortol pivalate</a>. </p> <h3>By route of administration</h3> <h4>Topical steroids</h4> <p class="note">Main article: <a href="/facts/Topical_steroid/jjT4BCVs">Topical steroid</a></p> <p>For use topically on the skin, eye, and <a href="/facts/Mucous_membrane/oIw0vyel">mucous membranes</a>. </p><p>Topical corticosteroids are divided in potency classes I to IV in most countries (A to D in Japan). Seven categories are used in the United States to determine the level of potency of any given topical corticosteroid. </p> <h4>Inhaled steroids</h4> <p>For nasal mucosa, sinuses, bronchi, and lungs.<a class="footnote-ref" id="fnref:54" href="#fn:54"><sup>54</sup></a> </p><p>This group includes: </p> <ul><li><a href="/facts/Flunisolide/dK3ed1Ss">Flunisolide</a><a class="footnote-ref" id="fnref:55" href="#fn:55"><sup>55</sup></a></li> <li><a href="/facts/Fluticasone_furoate/x4IRskxp">Fluticasone furoate</a><a class="footnote-ref" id="fnref:56" href="#fn:56"><sup>56</sup></a></li> <li><a href="/facts/Fluticasone_propionate/MfnCWC1x">Fluticasone propionate</a><a class="footnote-ref" id="fnref:57" href="#fn:57"><sup>57</sup></a></li> <li><a href="/facts/Triamcinolone_acetonide/8oe3CSR5">Triamcinolone acetonide</a><a class="footnote-ref" id="fnref:58" href="#fn:58"><sup>58</sup></a></li> <li><a href="/facts/Beclomethasone_dipropionate/T0rSDyEx">Beclomethasone dipropionate</a><a class="footnote-ref" id="fnref:59" href="#fn:59"><sup>59</sup></a></li> <li><a href="/facts/Budesonide/4p8z8WBy">Budesonide</a><a class="footnote-ref" id="fnref:60" href="#fn:60"><sup>60</sup></a></li> <li><a href="/facts/Mometasone_furoate/ALWaB4xR">Mometasone furoate</a></li> <li><a href="/facts/Ciclesonide/Bpp4KQXb">Ciclesonide</a></li></ul> <p>There also exist certain combination preparations such as <a href="/facts/Advair_Diskus/t4uhVlTN">Advair Diskus</a> in the United States, containing <a href="/facts/Fluticasone/salmeterol/t4uhVlTN">fluticasone propionate and salmeterol</a> (a long-acting bronchodilator), and <a href="/facts/Symbicort/nVkLkDBr">Symbicort</a>, containing <a href="/facts/Budesonide/formoterol/nVkLkDBr">budesonide and formoterol fumarate dihydrate</a> (another long-acting bronchodilator).<a class="footnote-ref" id="fnref:61" href="#fn:61"><sup>61</sup></a> They are both approved for use in children over 12 years old. </p> <h4>Oral forms</h4> <p>Such as prednisone, prednisolone, <a href="/facts/Methylprednisolone/wzGSj2jQ">methylprednisolone</a>, or <a href="/facts/Dexamethasone/rwAhDqls">dexamethasone</a>.<a class="footnote-ref" id="fnref:62" href="#fn:62"><sup>62</sup></a> </p> <h4>Systemic forms</h4> <p>Available in injectables for intravenous and parenteral routes.<a class="footnote-ref" id="fnref:63" href="#fn:63"><sup>63</sup></a> </p> <h2 id="history">History</h2> Introduction of early corticosteroids<a class="footnote-ref" id="fnref:64" href="#fn:64"><sup>64</sup></a><a class="footnote-ref" id="fnref:65" href="#fn:65"><sup>65</sup></a><a class="footnote-ref" id="fnref:66" href="#fn:66"><sup>66</sup></a><table><tbody><tr><th>Corticosteroid</th><th>Introduced</th></tr><tr><td><a href="/facts/Cortisone/z5GUmvNG">Cortisone</a></td><td>1948</td></tr><tr><td><a href="/facts/Hydrocortisone/zvRCrYXG">Hydrocortisone</a></td><td>1951</td></tr><tr><td><a href="/facts/Fludrocortisone_acetate/BpDJfgJd">Fludrocortisone acetate</a></td><td>1954<a class="footnote-ref" id="fnref:67" href="#fn:67"><sup>67</sup></a></td></tr><tr><td><a href="/facts/Prednisolone/aAB8cAPv">Prednisolone</a></td><td>1955</td></tr><tr><td><a href="/facts/Prednisone/eGgPIauI">Prednisone</a></td><td>1955<a class="footnote-ref" id="fnref:68" href="#fn:68"><sup>68</sup></a></td></tr><tr><td><a href="/facts/Methylprednisolone/wzGSj2jQ">Methylprednisolone</a></td><td>1956</td></tr><tr><td><a href="/facts/Triamcinolone/egxMoRSg">Triamcinolone</a></td><td>1956</td></tr><tr><td><a href="/facts/Dexamethasone/rwAhDqls">Dexamethasone</a></td><td>1958</td></tr><tr><td><a href="/facts/Betamethasone/qM3DSjSR">Betamethasone</a></td><td>1958</td></tr><tr><td><a href="/facts/Triamcinolone_acetonide/8oe3CSR5">Triamcinolone acetonide</a></td><td>1958</td></tr><tr><td><a href="/facts/Fluorometholone/25IVFMPt">Fluorometholone</a></td><td>1959</td></tr><tr><td><a href="/facts/Deflazacort/TEHtqnaC">Deflazacort</a></td><td>1969<a class="footnote-ref" id="fnref:69" href="#fn:69"><sup>69</sup></a></td></tr></tbody></table> <p><a href="/facts/Tadeusz_Reichstein/tVVPze2q">Tadeusz Reichstein</a>, <a href="/facts/Edward_Calvin_Kendall/8xLnvbfz">Edward Calvin Kendall</a>, and <a href="/facts/Philip_Showalter_Hench/8bfbKXP0">Philip Showalter Hench</a> were awarded the <a href="/facts/Nobel_Prize/3z1Y3oFL">Nobel Prize</a> for <a href="/facts/Physiology/fh25y2pQ">Physiology</a> and <a href="/facts/Medicine/2fnp90Je">Medicine</a> in 1950 for their work on hormones of the adrenal cortex, which culminated in the isolation of <a href="/facts/Cortisone/z5GUmvNG">cortisone</a>.<a class="footnote-ref" id="fnref:70" href="#fn:70"><sup>70</sup></a> </p><p>Initially hailed as a <a href="/facts/Miracle/W9KGIGPh">miracle</a> cure and liberally prescribed during the 1950s, steroid treatment brought about <a href="/facts/Adverse_events/6zKwT4g5">adverse events</a> of such a magnitude that the next major category of anti-inflammatory drugs, the <a href="/facts/Nonsteroidal_anti-inflammatory_drug/coIkzl4s">nonsteroidal anti-inflammatory drugs</a> (NSAIDs), was so named in order to demarcate from the opprobrium.<a class="footnote-ref" id="fnref:71" href="#fn:71"><sup>71</sup></a> </p><p><a href="/facts/Lewis_Sarett/zlThJYLk">Lewis Sarett</a> of <a href="/facts/Merck_%26_Co./8YD8dvwR">Merck & Co.</a> was the first to synthesize cortisone, using a 36-step process that started with deoxycholic acid, which was extracted from <a href="/facts/Ox/BHUFavVC">ox</a> <a href="/facts/Bile/7c5ufDao">bile</a>.<a class="footnote-ref" id="fnref:72" href="#fn:72"><sup>72</sup></a> The low efficiency of converting deoxycholic acid into cortisone led to a cost of US$200 per gram in 1947. <a href="/facts/Russell_Marker/g6hWAgHc">Russell Marker</a>, at <a href="/facts/Syntex/HCK66DP1">Syntex</a>, discovered a much cheaper and more convenient starting material, <a href="/facts/Diosgenin/Q5mTgo0f">diosgenin</a> from wild <a href="/facts/Mexican_yam/NJsI79rj">Mexican yams</a>. His conversion of diosgenin into <a href="/facts/Progesterone/WEj2TGRm">progesterone</a> by a four-step process now known as <a href="/facts/Marker_degradation/mkKcfdCM">Marker degradation</a> was an important step in mass production of all steroidal hormones, including cortisone and chemicals used in <a href="/facts/Hormonal_contraception/xVw5DPGT">hormonal contraception</a>.<a class="footnote-ref" id="fnref:73" href="#fn:73"><sup>73</sup></a> </p><p>In 1952, D.H. Peterson and H.C. Murray of <a href="/facts/Upjohn/CGST9bCw">Upjohn</a> developed a process that used <i><a href="/facts/Rhizopus/3XUqw4XJ">Rhizopus</a></i> mold to oxidize progesterone into a compound that was readily converted to cortisone.<a class="footnote-ref" id="fnref:74" href="#fn:74"><sup>74</sup></a> The ability to cheaply synthesize large quantities of cortisone from the diosgenin in yams resulted in a rapid drop in price to US$6 per gram[<i>when?</i>], falling to $0.46 per gram by 1980. <a href="/facts/Percy_Lavon_Julian/7xQ0Qe1q">Percy Julian's</a> research also aided progress in the field.<a class="footnote-ref" id="fnref:75" href="#fn:75"><sup>75</sup></a> The exact nature of cortisone's anti-inflammatory action remained a mystery for years after, however, until the <a href="/facts/Leukocyte_adhesion_cascade/IwFj8ejq">leukocyte adhesion cascade</a> and the role of <a href="/facts/Phospholipase_A2/ubWX9kQq">phospholipase A2</a> in the production of <a href="/facts/Prostaglandin/kIKw0gDj">prostaglandins</a> and <a href="/facts/Leukotriene/PxNEg3IS">leukotrienes</a> was fully understood in the early 1980s. </p><p>Corticosteroids were voted <a href="/facts/Allergen_of_the_Year/7Clyvzun">Allergen of the Year</a> in 2005 by the American Contact Dermatitis Society.<a class="footnote-ref" id="fnref:76" href="#fn:76"><sup>76</sup></a> </p> <h2 id="see-also">See also</h2> <ul><li><a href="/facts/List_of_corticosteroids/5RTV6Cdp">List of corticosteroids</a></li> <li><a href="/facts/List_of_corticosteroid_cyclic_ketals/SSK5Crre">List of corticosteroid cyclic ketals</a></li> <li><a href="/facts/List_of_corticosteroid_esters/42wevf0z">List of corticosteroid esters</a></li> <li><a href="/facts/List_of_steroid_abbreviations/X4yUst5R">List of steroid abbreviations</a></li></ul> <h2 id="references">References</h2> <ol> <li id="fn:1"><p>Nussey S, Whitehead S (2001). "The adrenal gland". Endocrinology: An Integrated Approach. Oxford: BIOS Scientific Publishers. <a href="https://www.ncbi.nlm.nih.gov/books/NBK26/." target="_blank">https://www.ncbi.nlm.nih.gov/books/NBK26/.</a> <a href="#fnref:1" class="footnote-back-ref">↩</a></p></li> <li id="fn:2"><p>Nussey S, Whitehead S (2001). "The adrenal gland". Endocrinology: An Integrated Approach. Oxford: BIOS Scientific Publishers. <a href="https://www.ncbi.nlm.nih.gov/books/NBK26/." target="_blank">https://www.ncbi.nlm.nih.gov/books/NBK26/.</a> <a href="#fnref:2" class="footnote-back-ref">↩</a></p></li> <li id="fn:3"><p>Liu D, Ahmet A, Ward L, Krishnamoorthy P, Mandelcorn ED, Leigh R, et al. (August 2013). "A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy". Allergy, Asthma, and Clinical Immunology. 9 (1): 30. doi:10.1186/1710-1492-9-30. PMC 3765115. PMID 23947590. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765115" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765115</a> <a href="#fnref:3" class="footnote-back-ref">↩</a></p></li> <li id="fn:4"><p>Liu D, Ahmet A, Ward L, Krishnamoorthy P, Mandelcorn ED, Leigh R, et al. (August 2013). "A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy". Allergy, Asthma, and Clinical Immunology. 9 (1): 30. doi:10.1186/1710-1492-9-30. PMC 3765115. PMID 23947590. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765115" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765115</a> <a href="#fnref:4" class="footnote-back-ref">↩</a></p></li> <li id="fn:5"><p>Liu D, Ahmet A, Ward L, Krishnamoorthy P, Mandelcorn ED, Leigh R, et al. (August 2013). "A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy". Allergy, Asthma, and Clinical Immunology. 9 (1): 30. doi:10.1186/1710-1492-9-30. PMC 3765115. PMID 23947590. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765115" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765115</a> <a href="#fnref:5" class="footnote-back-ref">↩</a></p></li> <li id="fn:6"><p>Liu D, Ahmet A, Ward L, Krishnamoorthy P, Mandelcorn ED, Leigh R, et al. (August 2013). "A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy". Allergy, Asthma, and Clinical Immunology. 9 (1): 30. doi:10.1186/1710-1492-9-30. PMC 3765115. PMID 23947590. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765115" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765115</a> <a href="#fnref:6" class="footnote-back-ref">↩</a></p></li> <li id="fn:7"><p>Liu D, Ahmet A, Ward L, Krishnamoorthy P, Mandelcorn ED, Leigh R, et al. (August 2013). "A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy". Allergy, Asthma, and Clinical Immunology. 9 (1): 30. doi:10.1186/1710-1492-9-30. PMC 3765115. PMID 23947590. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765115" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765115</a> <a href="#fnref:7" class="footnote-back-ref">↩</a></p></li> <li id="fn:8"><p>Liu D, Ahmet A, Ward L, Krishnamoorthy P, Mandelcorn ED, Leigh R, et al. (August 2013). "A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy". Allergy, Asthma, and Clinical Immunology. 9 (1): 30. doi:10.1186/1710-1492-9-30. PMC 3765115. PMID 23947590. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765115" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765115</a> <a href="#fnref:8" class="footnote-back-ref">↩</a></p></li> <li id="fn:9"><p>Faggiano A, Mazzilli R, Natalicchio A, Adinolfi V, Argentiero A, Danesi R, et al. (December 2022). "Corticosteroids in oncology: Use, overuse, indications, contraindications. An Italian Association of Medical Oncology (AIOM)/ Italian Association of Medical Diabetologists (AMD)/ Italian Society of Endocrinology (SIE)/ Italian Society of Pharmacology (SIF) multidisciplinary consensus position paper". Critical Reviews in Oncology/Hematology. 180: 103826. doi:10.1016/j.critrevonc.2022.103826. hdl:10447/582211. PMID 36191821. S2CID 252663155. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:9" class="footnote-back-ref">↩</a></p></li> <li id="fn:10"><p>Liu D, Ahmet A, Ward L, Krishnamoorthy P, Mandelcorn ED, Leigh R, et al. (August 2013). "A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy". Allergy, Asthma, and Clinical Immunology. 9 (1): 30. doi:10.1186/1710-1492-9-30. PMC 3765115. PMID 23947590. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765115" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3765115</a> <a href="#fnref:10" class="footnote-back-ref">↩</a></p></li> <li id="fn:11"><p>Mohamadi A, Chan JJ, Claessen FM, Ring D, Chen NC (January 2017). "Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis". Clinical Orthopaedics and Related Research. 475 (1): 232–243. doi:10.1007/s11999-016-5002-1. PMC 5174041. PMID 27469590. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5174041" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5174041</a> <a href="#fnref:11" class="footnote-back-ref">↩</a></p></li> <li id="fn:12"><p>Werner R (2005). A massage therapist's guide to Pathology (3rd ed.). Pennsylvania: Lippincott Williams & Wilkins. <a href="#fnref:12" class="footnote-back-ref">↩</a></p></li> <li id="fn:13"><p>Carvalho-Recchia CA, Yannuzzi LA, Negrão S, Spaide RF, Freund KB, Rodriguez-Coleman H, et al. (October 2002). "Corticosteroids and central serous chorioretinopathy". Ophthalmology. 109 (10): 1834–1837. doi:10.1016/S0161-6420(02)01117-X. PMID 12359603. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:13" class="footnote-back-ref">↩</a></p></li> <li id="fn:14"><p>"The New York Times :: A Breathing Technique Offers Help for People With Asthma". buteykola.com. Archived from the original on 2012-07-24. 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