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Topical steroids are used to treat a variety of inflammatory diseases, such as rheumatoid arthritis, gout, and osteoarthritis. They are highly effective at reducing pain and improving joint function. However, there have been reports of patients experiencing muscle cramps and myopathy as a result of steroid treatment. Myopathy is a condition that causes muscle weakness, which can interfere with everyday activities such as climbing stairs or lifting objects. It is believed that an excess of corticosteroids, either endogenous or exogenous, leads to the development of myopathy. This raises the question: Can topical steroids cause muscle cramps and myopathy?
| Characteristics | Values |
|---|---|
| Types of steroid-induced myopathy | Acute and chronic |
| Cause of myopathy | Excess of endogenous or exogenous corticosteroids |
| Endogenous corticosteroid excess causes | Adrenal tumors |
| Exogenous corticosteroid excess causes | Steroid treatment for asthma, chronic obstructive pulmonary disease, rheumatoid arthritis, polymyositis, connective tissue disorders, and inflammatory processes |
| Medications | Prednisone, cortisone, dexamethasone, fludrocortisone |
| Effect on muscles | Decreased protein synthesis, increased protein catabolism, atrophy |
| Muscle cramps | Common during early treatment stages, especially at night and in the hands and feet |
| Muscle weakness | Affecting the arms, legs, and pelvis symmetrically; may be improved with regular exercise |
| Muscle pain | Rare |
| Treatment | Reducing or stopping steroids; switching to a different steroid or altering dosage; physical therapy |
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What You'll Learn
Corticosteroids can cause muscle cramps and myopathy
There are two types of steroid myopathy: acute and chronic. The acute form is less common and occurs suddenly while a patient is receiving high doses of corticosteroids. It is associated with rhabdomyolysis, which involves the breakdown of muscle tissue and the release of muscle fibre contents into the bloodstream. This can lead to severe muscle pain and damage to the kidneys.
The chronic form of steroid myopathy, also known as the classic form, develops after prolonged use of corticosteroids. It typically occurs after weeks or months of therapy, with higher doses increasing the risk of myopathy. The fluorinated corticosteroids, including triamcinolone, betamethasone, and dexamethasone, are particularly likely to cause myopathy. The pathogenesis likely involves impairment of muscle protein and carbohydrate metabolism, leading to selective atrophy of type 2, glycolytic muscle fibres without muscle degeneration or inflammation.
The treatment goal for corticosteroid-induced myopathy is to reduce the corticosteroid dose as much as possible. Recovery may take weeks to months, and in some cases, it can be prolonged, exceeding six months. Physical therapy, including aerobic and resistance exercises, is an effective way to treat and prevent muscle atrophy in patients with corticosteroid-induced myopathy. This type of therapy has been shown to improve skeletal muscle strength significantly.
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Myopathy affects muscles in arms, legs and pelvis
Myopathy is a general term for diseases that affect the muscles that connect to bones (skeletal muscles). Myopathies may be passed down in families (inherited) or may develop later in life (acquired). Myopathies typically involve motor impairment without any sensory symptoms. They usually present as muscle weakness, most commonly in the upper arms, shoulders, and thighs, and can cause difficulty in performing daily activities such as bathing, dressing, or combing hair.
Steroid myopathy is caused by an excess of either endogenous or exogenous corticosteroids. Endogenous corticosteroid excess can arise from adrenal tumors, while exogenous corticosteroid excess can result from steroid treatment for conditions such as asthma, chronic obstructive pulmonary disease, polymyositis, connective tissue disorders, and rheumatoid arthritis. There are two types of steroid myopathy: acute and chronic. The acute form is less common and occurs abruptly while the patient receives high-dose corticosteroids. The chronic form occurs after prolonged corticosteroid use and has a more gradual onset.
Toxic myopathy is caused by toxins or medications that interfere with muscle structure or function. Toxins include alcohol and toluene, which can be inhaled through substances like spray paint. Medications that can cause toxic myopathy include corticosteroids (prednisone), cholesterol-lowering drugs (statins), and antivirals, among others.
Endocrine myopathies are caused by hormonal interference with muscle function. This includes thyroid disorders such as hypothyroidism and hyperthyroidism, hyperparathyroidism, and adrenal disorders such as Addison's disease and Cushing syndrome.
Infectious myopathies occur due to infections that affect muscle function.
Treatment for myopathies generally focuses on addressing the underlying cause. While there is no cure for genetic myopathy, various treatment options are available to manage symptoms. Acquired myopathies due to autoimmune diseases, such as dermatomyositis and polymyositis, can be treated with medications that reduce the body's immune response and decrease inflammation, including corticosteroids or other immunosuppressants.
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Steroid myopathy can be acute or chronic
Steroid myopathy is a disease process that causes weakness mainly to the proximal muscles of the upper and lower limbs and the neck flexors. It was first described by Cushing in 1932 and was first studied systemically by Muller and Kugelberg in 1959. Steroid myopathy can be acute or chronic.
The chronic form of steroid myopathy, also known as the classic form, occurs after prolonged use of corticosteroids and has a more gradual onset. It is a highly prevalent toxic non-inflammatory myopathy caused by chronic high-to-moderate systemic corticosteroid use. It typically develops with doses higher than 10 mg prednisone equivalents per day used for four weeks or longer. Elderly patients are most at risk due to lower baseline muscle mass, as are patients with oncological diseases. The determination of corticosteroid-induced myopathy is made when symptoms improve with tapering or discontinuing corticosteroids.
The acute form of steroid myopathy is less common and occurs abruptly while the patient is receiving high doses of corticosteroids. It is associated with rhabdomyolysis. Acute steroid myopathy has been observed in patients in the intensive care setting undergoing mechanical ventilation and receiving curare-like paralytics, with doses of methylprednisolone greater than 60 mg/day for 5 to 7 days. In acute steroid myopathy, recovery may be prolonged, taking more than six months.
Treatment for steroid myopathy typically involves corticosteroid withdrawal or tapering. In some cases, switching from fluorinated to non-fluorinated glucocorticoids or alternate-day dosing may be considered. Physical therapy, including resistance and aerobic exercise, has been shown to prevent and treat steroid-induced myopathy.
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Myopathy is reversible after stopping treatment
Steroid-induced myopathy is caused by an excess of either endogenous or exogenous corticosteroids. Endogenous corticosteroid excess can arise from adrenal tumours, while exogenous corticosteroid excess can result from steroid treatments for asthma, chronic obstructive pulmonary disease, and inflammatory processes such as rheumatoid arthritis.
Corticosteroid-induced myopathy is a toxic non-inflammatory myopathy that typically affects the pelvic girdle muscles and is associated with muscle weakness and atrophy without pain. It is important to note that higher doses of corticosteroids are more likely to induce clinical myopathy. The chronic form of steroid myopathy occurs after prolonged use of corticosteroids and has a more gradual onset, whereas the acute form is less common and occurs abruptly with high-dose corticosteroid use.
The good news is that steroid-induced myopathy is reversible. If stopping steroid treatment is not an option, adjusting the type or dosage of steroids may help alleviate symptoms. Physical therapy, including resistance and aerobic exercise, is also recommended to prevent and treat corticosteroid-induced myopathy. Patients should be educated about the risks and benefits of corticosteroids and the importance of physical activity.
Recovery from steroid-induced myopathy may take weeks to months after reducing or discontinuing the corticosteroid dose. In some cases, full recovery may not be achieved, and chronic and irreversible changes can occur if steroids are continued despite the onset of myopathy. Therefore, prompt initiation of treatment in the form of corticosteroid withdrawal is crucial to avoid the potential morbidity associated with the condition.
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Physical therapy can prevent and treat steroid-induced myopathy
While topical steroids are not typically associated with muscle cramps, oral or intravenous corticosteroids can lead to steroid-induced myopathy, a condition causing muscle weakness and atrophy. This condition can be acute or chronic, with the latter occurring after prolonged use of corticosteroids.
Physical therapy, in the form of aerobic and resistance exercises, has been shown to be effective in preventing and treating steroid-induced myopathy. This includes range-of-motion exercises (passive, active-assisted, or active), stretching exercises, and resistance training. For patients unable to taper off steroids, a monitored resistance training regimen has been found to successfully reverse corticosteroid-induced muscle atrophy and improve skeletal muscle strength. In one study, heart transplant recipients on chronic glucocorticoids who underwent a 6-month regimen of monitored resistance training experienced a 400-600% improvement in skeletal muscle strength compared to a control group.
In addition to physical therapy, other treatments for steroid-induced myopathy include experimental agents such as exogenous IGF-I, branched-chain amino acids, creatine, androgens (testosterone, nandrolone, DHEA), and glutamine. These treatments have been investigated in animal models but have not been conclusively evaluated in humans and are not currently recommended. An adequate protein intake is also helpful in preventing the rapid acceleration of symptoms.
It is important to note that high-intensity exercise should be avoided, as preliminary animal research models suggest it may be harmful. Additionally, in cases of myopathy caused by long-term corticosteroid use, decreasing the corticosteroid dose below 30 mg/day may resolve muscle weakness.
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Frequently asked questions
Yes, topical steroids can cause muscle cramps. This is a known side effect of steroid use, particularly in the early stages of treatment.
Steroid-induced myopathy typically causes muscle weakness, making everyday activities like climbing stairs or lifting objects difficult. In some cases, patients may also experience muscle pain and tenderness.
Yes, chronic steroid use can lead to permanent muscle damage and weakness. Even after discontinuing steroid treatment, the recovery process may take weeks or even months.
The most effective treatment is to reduce or discontinue steroid use. Physical therapy and regular exercise can also help improve muscle strength and speed up recovery. In some cases, changing the type of steroid or altering the dosage may be recommended.
Yes, low-dose naltrexone and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen are possible alternatives to topical steroids. However, it is important to consult a doctor or healthcare professional before starting any new medication.
