Complications
Glucocorticoid-induced bone loss is the most predictable and debilitating complication of prolonged administration of systemic corticosteroids. Significant bone loss and increased fracture risk is seen with daily prednisone doses as low as 5 mg.[54] Alternate-day glucocorticoid therapies can lead to similar bone loss.
No conclusive evidence exists for a safe minimum dose or duration of glucocorticoid exposure, so physicians should consider individual osteoporosis risk factors such as older age, postmenopausal status, and baseline bone density measurements in the assessment of patients.
Current guidelines for glucocorticoid-induced osteoporosis management recommend bisphosphonates, especially alendronate and risedronate, as first-line agents for treatment. These guidelines propose the preventive use of bisphosphonates early in the course of glucocorticoid therapy in high-risk patient subgroups.[55]
The presence of extensive areas of denuded skin in combination with immunosuppressive treatment increases susceptibility to secondary infections. The infections may be systemic or limited to the skin; both will delay healing of the skin lesions.
Patients with aggressive or widespread disease, those requiring high doses of corticosteroids and immunosuppressive agents, and those with underlying medical problems have increased risk of death.[53][52][7] The estimated death rate is between 6% and 41% in the first year.[50][51] The proximal causes of death are infection with sepsis and adverse events associated with treatment.
In a survey of patients in one US university medical center, there was no difference between the mortality of 223 bullous pemphigoid patients and the general population.[52] However, cohort studies in the UK and France reported the risk of death was 2 to 6 times greater in bullous pemphigoid patients compared with the general population.[7][8]
In one multivariate analysis, age ≥86 years, poor general condition, female sex, and generalized disease were associated with increased risks of death at 6 months.[53] Results of a randomized controlled trial carried out in 20 dermatology departments in France indicated that only older age (P=0.02) and a low Karnofsky score (P <0.001) appeared to independently predict death.[25]
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