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Analysis of Statistical Impact of Steroids in Professional Major League Baseball Players

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Steroid Use and Long-Term Health Risks in Former Athletes

• Current Opinion
• Published: 02 November 2012
• Volume 32 , pages 83–94, ( 2002 )

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• Miia Pärssinen 1 &
• Timo Seppälä 1  

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This article focuses on anabolic steroid adverse effects on the cardiovascular system and mental health issues as well as the possible increase in the incidence of neoplasms in anabolic steroid users. On the basis of findings in the literature, the authors consider these three issues as the most significant concerning morbidity and mortality among anabolic steroid users. A study by Pärssinen et al. (2000) has shown an increased incidence of premature mortality among power lifters. Anabolic steroids and other concomitantly used drugs are the probable cause of this increased mortality, as power training itself does not increase health risks and all types of physical activity promote health.

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Consequences of the Use of Anabolic-Androgenic Steroids on Female Athletes’ Fertility

Quality controls.

National Institute on Drug Abuse (NIDA). About anabolic steroid abuse [Tearoff]. NIDA Notes 2000 Aug; 15 (3): 15

Google Scholar  

Bhasin S, Storer TW, Berman N, et al. The effects of supra-physiological doses of testosterone on muscle size and strength in normal men. N Engl J Med 1996; 335 (1): 1–7

Article   PubMed   CAS   Google Scholar  

Lin GC, Erinoff L, editors. Anabolic Steroid Abuse. Rockvilee (MD): National Institute on Drug Abuse, 1990 (NIDA Research Monograph Series 102)

Jänne OA, Palvimo J, Kallio P, et al. Androgen receptor and mechanism of androgen action. Ann Med 1993; 25: 83–9

Article   PubMed   Google Scholar  

LeGros T, McDonnell D, Murry T, et al. The effects of 17α-methyltestosterone on myocardial function in vitro. Med Sci Sports Exerc 2000; 32 (5): 897–903

PubMed   CAS   Google Scholar  

Melchert RB, Welder AA. Cardiovascular effects of androgenic anabolic steroids. Med Sci Sports Exerc 1995; 27 (9): 1252–62

Sullivan ML, Martinez CM, Gennis P, et al. The cardiac toxicity of anabolic steroids. Prog Cardiovasc Dis 1998; 41 (1): 1–15

Bahrke MS, Yesalis CE, Wright JE. Psychological and behavioural effects of endogenous testosterone and anabolic-androgenic steroids. Sports Med 1996; 22 (6): 367–90

Boada LD, Zumbado M, Torres S, et al. Evaluation of acute and chronic hepatotoxic effects exerted by anabolic-androgenic steroid stanozolol in adult male rats. Arch Toxicol 1999 Nov; 73 (8–9): 465–72

Bronson FH, Matherne CM. Exposure to anabolic-androgenic steroids shortens life span of male mice. Med Sci Sports Exerc 1997; 29 (5): 615–9

Brower KJ. Anabolic steroids. Psychiatr Clin North Am 1993; 16 (1): 97–103

Haupt HA. Anabolic steroids and growth hormone. Am J Sports Med 1993; 21 (3): 468–74

Haupt HA, Rovere GD. Anabolic steroids: a review of the literature. Am J Sports Med 1984; 12 (6): 469–84

Kibble MW, Ross MB. Adverse effects of anabolic steroids. Clin Pharm 1987; 6: 686–92

Yesalis Charles E. Anabolic steroids in sport and exercise. Champaign (IL): Human Kinetics Publishers, 1993

Sarna S, Sahi T, Koskenvuo M, et al. Increased life expectancy of world class male athletes. Med Sci Sports Exerc 1993; 25 (2): 237–44

Fogelholm M, Kaprio J, Sarna S. Healthy lifestyles of former Finnish world class athletes. Med Sci Sports Exerc 1994; 26 (2): 224–9

Kujala UM, Kaprio J, Taimela S, et al. Prevalence of diabetes, hypertension, and ischemic heart disease in former elite athletes. Metabolism 1994; 43 (10): 1255–60

Wight Jr JN, Salem D. Sudden cardiac death and the ‘athlete’s heart”. Arch Intern Med 1995; 155: 1473–80

Tikkanen HO, Härkönen M, Näveri H. Relationship of skeletal muscle fiber type to serum high density lipoprotein cholesterol and apolipoprotein A-I levels. Atherosclerosis 1991; 90: 49–57

Tikkanen HO, Hämäläinen E, Sarna S, et al. Association between skeletal muscle properties, physical fitness, physical activity and coronary heart disease risk factors in men. Atherosclerosis 1998; 137: 337–89

Article   Google Scholar  

Wade AJ, Marbut MM, Round JM. Muscle fiber type and aetiology of obesity. Lancet 1990; 335: 805–8

Kujala UM, Sarna S, Kaprio J, et al. Natural selection to sports, later physical activity habits and coronary heart disease. Br J Sports Med 2000; 34: 445–9

Palatini P, Giada F, Garavelli G, et al. Cardiovascular effects of anabolic steroids in weight-trained subjects. J Clin Pharmacol 1996; 36: 1132–40

Dickerman RD, McConathy WJ, Schaller F, et al. Echocardigraphy in fraternal twin bodybuilders with one abusing anabolic steroids. Cardiology 1997; 88: 50–1

Dickerman RD, Schaller F, McConathy WJ. Left ventricular wall thickening does occur in elite power athletes with or without anabolic steroid use. Cardiology 1998; 90: 145–8

Nieminen MS, Rämö MP, Viitasalo M, et al. Serious cardiovascular side effects of large doses of anabolic steroids in weight lifters. Eur Heart J 1996; 17: 1576–83

Anastasiou-Nana MI, Nanas JN, Karagounis LA, et al. Relation of dispersion of QRS and QT in patients with advanced congestive heart failure to cardiac and sudden death mortality. Am J Cardiol 2000; 85 (10): 1212–7

Stolt A, Karila T, Viitasalo M, et al. QT interval and QT dispersion in endurance athletes and in power athletes using large doses of anabolic steroids. Am J Cardiol 1999; 84 (3): 364–6

McCarthy K, Tang ATM, Dalrymple-Hay MJR, et al. Ventricular thrombosis and systemic embolism in bodybuilders: etiology and management. Ann Thorac Surg 2000; 70: 658–60

Hausmann R, Hammer S, Betz P. Performance enhancing drugs (doping agents) and sudden death: a case report and review of the literature. Int J Legal Med 1998; 111: 261–4

Maron BJ, Shirani J, Poliac LC, et al. Sudden death in young competitive athletes, clinical, demographic and pathological profiles. JAMA 1996; 276: 199–204

Maron BJ, Poliac LC, Roberts WO. Risk for sudden cardiac death associated with marathon running. J Am Coll Cardiol 1996; 28 (2): 428–31

Kenny A, Shapiro LM. Sudden cardiac death in athletes. Br Med Bull 1992; 48 (3): 534–45

Jensen-Urstad M. Sudden death and physical activity in athletes and nonathletes. Scand J Med Sci Sports 1995; 5: 279–84

Luke JL, Farb A, Virmani R, et al. Sudden cardiac death during exercise in a weight lifter using anabolic androgenic steroids: pathological and toxicological findings. J Forensic Sci 1990; 35: 1441–7

Lynberg K. Myocardial infarction and death of a body builder after using anabolic steroids. Ugeskr Laeger 1991; 153: 587–8

Uzych L. Anabolic-androgenic steroids and psychiatric-related effects: a review. Can J Psychiatry 1992; 37 (1): 23–7

Bahrke MS, Wright JE, Strauss RH, et al. Psychological moods and subjectively perceived behavioral and somatic changes accompanying anabolic-androgenic steroid use. Am J Sports Med 1992; 20 (6): 717–24

Pope HG, Katz DL. Psychiatric and medical effects of anabolic-androgenic steroid use: a controlled study of 160 athletes. Arch Gen Psychiatry 1994; 51 (5): 375–82

Pope HG, Kouri EM, Hudson JI. Effects of supraphysiologic doses of testosterone on mood and aggression in normal men: a randomized controlled trial. Arch Gen Psychiatry 2000; 57 (2): 133–40

Hannan C, Friedl K, Zold A, et al. Psychological and serum homovanillic acid changes in men administered androgenic steroids. Psychoneuroendocrinology 1991; 16: 335–42

Su T-P, Pagliaro M, Schmidt P, et al. Neuropsychiatric effects of anabolic steroids in male normal volunteers. JAMA 1993; 269 (21): 2760–4

Thiblin I, Runeson B, Rajs J. Anabolic androgenic steroids and suicide. Ann Clin Psychiatry 1999; 11 (4): 223–31

Thiblin I, Lindquist O, Rajs J. Cause and manner of death among users of anabolic androgenic steroids. J Forensic Sci 2000; 45 (1): 16–23

Brower KJ, Blow FC, Young JP, et al. Symptoms and correlates of anabolic-androgenic steroid dependence. Br J Addiction 1991; 86: 759–68

Article   CAS   Google Scholar  

Brower KJ, Blow FC, Beresford TP, et al. Anabolic-androgenic steroid dependence. J Clin Psychiatry 1989; 50 (1): 31–3

Chen CJ, Yu MW, Liaw YF. Epidemiological characteristics and risk factors of hepatocellular carcinoma. J Gastroenterol Hepatol 1997 Oct; 12 (9–10): S294–308

Zahm SH, Fraumeni Jr JF. The epidemiology of soft tissue sarcoma. Semin Oncol 1997 Oct; 24 (5): 504–14

CAS   Google Scholar  

Cho H, Lim IK. Expression of androgen receptor and its implication in hepatoma cells. Cancer 1997 May 19; 115 (2): 135–40

Tanaka K, Sakai H, Hashizume M, et al. Serum testosterone: estradiol ratio and the development of hepatocellular carcinoma among male cirrhotic patients. Cancer Res 2000 Sep 15; 60 (18): 5106–10

Nakao A, Sakagami K, Nakata Y, et al. Multiple hepatic adenomas caused by long-term administration of androgenic steroids for aplastic anemia in association with familial adenomatous polyposis. J Gastroenterol 2000; 35 (7): 557–62

de Menis E, Tramontin P, Conte N. Danazol and multiple hepatic adenomas: peculiar clinical findings in an acromegalic patient. Horm Metab Res 1999 Aug; 31 (8): 476–7

Heikkilä R, Aho K, Heliövaara M, et al. Serum testosterone and sex hormone-binding globulin concentrations and the risk of prostate cancer. Cancer 1999; 86: 312–5

Demark-Wahnefried W, Lesko SM, Conaway MR, et al. Serum androgens: associations with prostate cancer risk and hair patterning. J Androl 1997 Sep-Oct; 18 (5): 495–500

Signorello LB, Tzonou A, Mantzoros CS, et al. Serum steroids in relation to prostate cancer risk in a case-control study. Cancer Causes Control 1997 Jul; 8 (4): 632–6

Bryden AAG, Rothwell PJN, O’Reilly PH. Anabolic steroid abuse and renal-cell carcinoma. Lancet 1995; 346 (8985): 1306–7

Martorana G, Concetti S, Manferrari F, et al. Anabolic steroid abuse and renal cell carcinoma. Clin Urol 1999; 162 (11): 2089

Rosner F, Khan MT. Renal cell carcinoma following prolonged testosterone therapy. Arch Intern Med 1992; 152: 426, 429

Froehner M, Fischer R, Leike S, et al. Intratesticular leiomyosarcoma in a young man after high dose doping with Oral-Turinabol: a case report. Cancer 1999 Oct 15; 86 (8): 1571–5

Pärssinen M, Kujala U, Vartiainen E, et al. Increased premature mortality of competitive power lifters suspected to have used anabolic agents. Int J Sports Med 2000; 21: 225–7

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Pärssinen, M., Seppälä, T. Steroid Use and Long-Term Health Risks in Former Athletes. Sports Med 32 , 83–94 (2002). https://doi.org/10.2165/00007256-200232020-00001

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Home > Student Scholarship > HONORS_THESES > 308

Honors Theses

The World of Anabolic Steroids

Jeff T. Wischer , Eastern Kentucky University Follow

Jeff Wischer

Dr. Michael Lane Department of Exercise and Sport Science

My thesis topic revolves around anabolic steroids and the use and misuse of these drugs. So often in today’s society, we here about anabolic steroids and how detrimental they are to one’s health. We also often hear steroids that are associated with the sports world and sporting stars. Some of the key questions that my thesis topic focuses on include are the adverse effects associated with steroids true? Who are the main users of steroid? Why would someone use steroids? My thesis focuses on proper steroid usage vs steroid abuse and how this is a key aspect when it comes to the adverse effects of anabolic steroids. I will analyze how often proper steroid usage gets lumped into the same category as steroid abuse and will analyze the differences in the amount and severity of adverse effects that are produced by abuse vs proper use. I will analyze the effects caused to different body systems and look at the effects and differences between oral and injectable steroids. I will also look into why someone would abuse steroids and will analyze the three main reasons that are highlighted in the research as to why people abuse and misuse steroids instead of utilizing them properly.

Keywords: Honors Thesis, Eastern Kentucky, Anabolic Steroids, Anabolic Steroid Abuse, Undergraduate

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Spring 5-9-2016

Michael T. Lane

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Exercise and Sport Science

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Performance Enhancing Drugs in America's Pastime

Hodges, William A. (2014) Performance Enhancing Drugs in America's Pastime. Undergraduate thesis, under the direction of Dr. Charles Ross from History, The University of Mississippi.

Over the last couple of decades, steroids use has been a part of baseball. The goal of steroid users is to gain a physical advantage over other players in the league by taking these drugs. The drugs have a variety of different effects to benefit baseball players. Along with the benefits, steroids have many health risks. The history of steroids in baseball, although relatively recent, is still vast and is still being written. The MLB has worked hard to determine the proper action to deal with steroids. The first part of the thesis is to look into what steroids are and the effects they have on users, both positive and negative in determining if steroid use if worth the risk. The second part is to look into the history of steroid use in baseball, starting with Jose Canseco and going through the suspensions in 2013. The last part will look at the current policy on steroids and look at the future of the game and whether or not steroids should be legalized, and will show that steroids should remain illegal for the rest of baseball and those who used them should not be honored for their achievements. The primary resources for this include many articles from a variety of newspapers including the New York Times, USA Today, and many more. Another source of information includes the Mitchell Report to gain an understanding of the research MLB did to uncover the truth about steroid use. And finally Canseco’s books are used, as he is the one who started steroid use in baseball. Using these sources, the history of steroids in baseball is summarized here; ultimately concluding that steroid use has tainted baseball and should remain illegal.

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Home > Honors College > Honors Theses > 950

Honors Theses

Performance enhancing drugs in america's pastime.

William A. Hodges , University of Mississippi. Sally McDonnell Barksdale Honors College

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Charles Ross

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Over the last couple of decades, steroids use has been a part of baseball. The goal of steroid users is to gain a physical advantage over other players in the league by taking these drugs. The drugs have a variety of different effects to benefit baseball players. Along with the benefits, steroids have many health risks. The history of steroids in baseball, although relatively recent, is still vast and is still being written. The MLB has worked hard to determine the proper action to deal with steroids. The first part of the thesis is to look into what steroids are and the effects they have on users, both positive and negative in determining if steroid use if worth the risk. The second part is to look into the history of steroid use in baseball, starting with Jose Canseco and going through the suspensions in 2013. The last part will look at the current policy on steroids and look at the future of the game and whether or not steroids should be legalized, and will show that steroids should remain illegal for the rest of baseball and those who used them should not be honored for their achievements. The primary resources for this include many articles from a variety of newspapers including the New York Times, USA Today, and many more. Another source of information includes the Mitchell Report to gain an understanding of the research MLB did to uncover the truth about steroid use. And finally Canseco's books are used, as he is the one who started steroid use in baseball. Using these sources, the history of steroids in baseball is summarized here; ultimately concluding that steroid use has tainted baseball and should remain illegal.

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Hodges, William A., "Performance Enhancing Drugs in America's Pastime" (2014). Honors Theses . 950. https://egrove.olemiss.edu/hon_thesis/950

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A Complete Guide to Allergy Treatments

You’re sniffling, sneezing and staring at the pharmacy shelf. Here’s how to choose the right option for your symptoms.

By Nina Agrawal

With tree pollen counts already hitting peak levels in some parts of the United States, now is the time to start preparing for — and treating — your spring allergy symptoms .

But before you head to a pharmacy, consider some measures you can take at home. And if you do need to resort to medication, here’s what to know about the various pills, sprays and shots available.

Your first line of defense

Doctors recommend first trying to limit your exposure to whatever is triggering an allergic response — for example, tree pollen in the spring.

You can monitor local pollen levels on weather or allergy apps or on sites such as the National Allergy Bureau’s . When counts are high, doctors recommend keeping your windows closed, wearing a well-fitting mask outside and showering and changing your clothes when you get home. Pets can also bring in pollen from the outdoors, so keep them out of your bedroom and wash them regularly. When you come inside, you can also rinse out your nose with a saline spray or neti pot.

“It’s laborious, but the people who do this stuff find it really helpful,” said Dr. Neeta Ogden, a New-Jersey based allergist.

Nasal sprays

Dr. John Mafi, a primary care physician at UCLA Health who often treats patients with allergies, said that for those with moderate or severe seasonal allergies, the most effective treatment is typically a nasal corticosteroid spray.

These include fluticasone (Flonase), budesonide (Benacort), triamcinolone (Nasacort) and mometasone (Nasonex).

Allergens trigger inflammation in the nose, eyes, throat and, sometimes, the airway. “A local steroid is calming that area of inflammation,” Dr. Mafi said. Because nasal sprays are not absorbed systemically the way steroid pills are, they are considered low-risk, he added.

Spray with the nozzle pointed out toward the ears to get the greatest benefit and to avoid side effects like nose bleeds. The steroids can take several days to take effect, so doctors recommend using them from a week or two ahead of pollen season until pollen counts decline.

Antihistamines

Antihistamines reduce the itchiness and inflammation produced by histamine, a chemical your immune cells release when triggered by an allergen . They can be taken as pills, nasal sprays or eye drops. They work quickly and are most effective if taken as needed, such as on days when your symptoms are particularly bad.

“It can be like a rescue therapy,” said Dr. Farah Khan, an allergist and immunologist at Nationwide Children’s Hospital in Columbus, Ohio.

For itchy, watery eyes, antihistamine eye drops — often in conjunction with a nasal spray — tend to work best, Dr. Mafi said.

An oral antihistamine can be beneficial when you have multiple symptoms, like itchy eyes, a stuffy nose and hives, said Dr. Rita Kachru, chief of clinical allergy and immunology at UCLA Health.

In 2020, a task force of physicians that issues allergy treatment guidelines recommended against using “first-generation” oral antihistamines, such as diphenhydramine (Benadryl), for allergic rhinitis, especially on a chronic basis. The group cited negative side effects, including sedation, performance impairment and increased risk of dementia.

Doctors said the “second-generation” oral antihistamines loratadine (Claritin), cetirizine (Zyrtec) and fexofenadine (Allegra) won’t make most people drowsy, though patients are least likely to experience drowsiness with fexofenadine, Dr. Kachru said. These pills can cause side effects, including dry eyes or mouth and constipation.

If an antihistamine produces unpleasant side effects or stops working well, doctors suggest trying another one.

Decongestants

Some antihistamines, like Claritin-D and Allegra-D, come combined with pseudoephedrine (Sudafed). Doctors don’t recommend products that contain pseudoephedrine for children at all, or for adults for more than a few days in a row because the ingredient can increase heart rate and blood pressure.

Dr. Kachru also warned against using the decongestant nasal spray oxymetazoline (Afrin). Though it might provide relief, she said, over time you need more medication to get the same response. And stopping the medication can cause inflammation that can make it hard to breathe through your nose, she said.

Immunotherapy

Doctors recommend consulting a board-certified allergist if your symptoms are getting worse, interfering with daily life or causing other health problems, and medications aren’t helping. Dr. Ogden said patients often come to her when they can no longer tolerate taking medications for months on end.

“And then we have a talk about starting allergy shots,” she said.

Allergy shots deliver progressively higher doses of the protein you’re allergic to, teaching your immune system to tolerate it. The therapy, which has been approved by the Food and Drug Administration and is usually covered by insurance, has been shown to significantly reduce symptoms and medication use , and the effects can last for several years after treatment ends.

Another option is sublingual immunotherapy, in which you place a tablet containing the allergen under your tongue. The F.D.A. has approved tablets for ragweed, grasses and dust mites.

Both forms of immunotherapy require a substantial investment of time, usually three to five years. Scientists are studying other options. With climate change and air pollution making allergy symptoms worse, Dr. Ogden said, “I think immunotherapy is where we’re going to end up.”

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• v.11(5); Sep-Oct 2020

Use of Topical Steroids in Dermatology: A Questionnaire Based Study

Sonali r. karekar.

Department of Pharmacology and Therapeutics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Padmaja A. Marathe

Vetrivel babu nagarajan, uday s. khopkar.

1 Department of Dermatology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Siddhi B. Chikhalkar

Priyashree k. desai.

2 Department of Third Year MBBS Student, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Minakshi S. Dongre

Topical steroids, the most widely prescribed drugs in dermatology are being increasingly misused.

This study was conducted to assess knowledge and practices regarding the use of topical steroids and to analyze prescriptions containing topical steroids.

Subjects and Methods:

Following approval from the institutional ethics committee, participants were recruited as per the selection criteria and divided into those treated in the institution and those having outside prescription. They were administered a pre-validated questionnaire to assess knowledge and practices regarding the use of topical steroids.

Statistical Analysis Used:

Comparison of awareness between two patient categories was done using Chi-square test. Prescription variables were analyzed using descriptive statistics. Significance of P value was set at 0.05.

Out of 400 patients, 167 had external prescriptions whereas 233 were institutional patients. Only 5.5% of all patients knew about the type of drug prescribed whereas 31.25% were aware of the indication. A total of 33.75% of the patients knew topical steroids required a prescription and 5.6% said they were aware that topical steroid use was associated with side effects. Side effects were reported by 96 patients. Awareness regarding knowledge, indication, and need for prescription were significantly better in institutional patients whereas knowledge about side effects was lacking in both groups. Psoriasis was the most common indication overall whereas tinea was the most common indication (51.5%) among externally prescribed.

Conclusions:

Although this study showed that institutional patients had comparatively better knowledge than community-treated patients, there is a need to create more awareness among patients overall and implement measures to stop irrational prescribing practices in the community.

Introduction

Topical steroids are the most commonly prescribed drugs in dermatology. They are indicated in a variety of conditions such as psoriasis, atopic dermatitis, seborrheic dermatitis, intertrigo, eczema, and lichen simplex chronicus due to their anti-inflammatory, immunosuppressive, and anti-mitogenic effects.[ 1 ] Long-term use of topical steroids is associated with numerous side effects which are both topical and systemic. Locally, they cause atrophic changes in the skin such as striae, telangiectasia, stellate pseudoscars, hypopigmentation, fragile skin, ulceration, purpura, impaired wound healing, and facial hypertrichosis.[ 2 ] Moreover, topical steroids can increase local susceptibility to bacterial, fungal, and viral infections. To minimize the side effects of topical steroids; potency, delivery vehicle, frequency of administration, and site of application should be considered before prescribing.[ 3 ] Topical steroids are misused for skin infections, acne, and also as fairness creams. Young adults procure topical steroids over the counter and use them for a subjective feeling of better appearance. A study reported that more than half of the prescriptions of topical steroids were delivered for fungal infection. Availability over the counter, self-medication by patients, affordability, and poor health infrastructure make topical steroids one of the most commonly misused medications among the masses. The misuse is so rampant that a major proportion of dermatology-related clinical visits by patients is for complaints concerning the adverse effects related to excessive usage of topical steroids.[ 4 ]

There is a need to assess the practices regarding the use of topical steroids. Studies concerning steroid abuse have been reported from multiple countries including China,[ 5 ] Iraq,[ 6 ] and the USA[ 7 ] but the evidence is limited from Indian studies.[ 8 ] Owing to the growing menace of topical steroid abuse, there is a need to assess the awareness among masses regarding knowledge pertaining to the use of topical steroids. There have been no studies in India assessing the knowledge of the people regarding topical steroid use. Moreover, across the world too, very few studies have been conducted pertaining to this aspect.[ 9 , 10 , 11 ]

This study was conceptualized to assess knowledge and practices regarding the use of topical steroids and to analyze the prescription containing topical steroids in patients visiting dermatology clinic. The study also compared the awareness and practices of patients being prescribed topical steroids within the dermatology out-patient department (OPD) of the tertiary care hospital, to those reporting to the OPD with steroids prescribed from outside.

Subjects and Methods

This was an observational, cross-sectional study conducted in the dermatology OPD in a tertiary care hospital. It was initiated after obtaining permission from the institutional ethics committee (EC/148/2016) in January 2017 and was registered in the clinical trials registry of India. (CTRI No: CTRI/2017/12/010733) The study has been performed in accordance with Indian Good Clinical Practices and the Indian Council of Medical Research guidelines. Patients of either gender between the age group of 18 to 65 years, visiting dermatology OPD of tertiary care hospital receiving topical steroids continuously or intermittently for a period of at least 1 week or more were included after obtaining written informed consent. They were enrolled in the study over a period of 12 months from February 2017 to January 2018. The patients were enrolled as they attended the dermatology clinic (convenient sample) and formal sample size calculation was not done. The patients were divided on the basis of their initial prescription of topical steroids into institutionally prescribed (those who were initiated on topical steroid treatment in the tertiary care OPD) and externally prescribed (those reporting to the OPD with topical steroids initiated from outside) steroids. A pre-validated questionnaire was administered to the patients. The questionnaire contained 19 questions divided in two domains viz knowledge (type of drug prescribed, indication, side effects, and need for prescription) and practices domain (duration and pattern of use, type of prescriber, frequency of application, quantity of application, relief of symptoms, relapse, abrupt stoppage of drug, use of old prescriptions, over the counter purchase, side effects, and instructions regarding application). Demographic details, type of steroid received, duration prescribed, frequency, indication, and duration were noted down from the prescriptions. Side effects occurring due to the topical steroids were also asked and recorded.

Validation of the questionnaire was performed before administering the questionnaire to the participants. Face validity and content validity was done by ten experts. Face validity was done to assess the clarity of the wording, layout and style, and readability of the questions. For content validity, the experts were asked to rate the questions as essential, useful and nonessential. Content validity ratio [CVR] was calculated based on the ratings by the formula CVR = (n- N/2) ÷ N/2 [where ”n” = Number of experts who found the question essential/useful and ”N”= Total number of experts]. Test to check internal consistency for reliability was done.

Chi-square test was used to compare attributes such as knowledge of the drug, indications, need for a prescription, awareness about side effects, abrupt stoppage of topical steroids, use of old prescriptions, over the counter purchase of topical steroids, and side effects between externally prescribed and institutional patients. The prescription analysis data was analyzed using descriptive statistics. Level of significance was set at P < 0.05. Data analysis was done using SPSS for Windows, Version 16.0. Chicago, SPSS Inc.

A total of 400 patients were included in the study. Mean age of patients was 36.64 ± 12.73 years. The total number of male patients was 243 whereas females were 157. Out of 400, 167 patients were prescribed topical steroids from outside whereas 233 comprised the institutional patients. There were 20 questions in the questionnaire; out of which 19, with a CVR greater than or equal to 0.8 were retained. Internal consistency for the reliability value of Cronbach's alpha for the questionnaire was calculated to be 0.71.

Table 1 depicts responses to the knowledge domain of the questionnaire. Out of 400 patients, 5.5% of patients knew about the type of drug prescribed. When asked about the indication for prescription, 68.75% were not aware of the same. Knowledge regarding side effects of topical steroids was found to be lacking with only 5.6% people knowing that steroids use was associated with side effects. Moreover, 66.25% of the patients did not know that procuring topical steroids required a prescription. The comparison between two patient groups showed that the knowledge regarding the type of drug, indications, and need for prescription was significantly better in the institutional patients as compared to the externally prescribed group ( P < 0.05). However, awareness regarding side effects was missing in both groups.

Analysis of favourable responses to the knowledge domain of the questionnaire

Statistical analysis was done using Chi-square test, P <0.05 was considered significant*

Out of all 400 patients, 77.25% patients reported relief. The earliest symptom to be relieved was itching followed by redness. In acute conditions, duration of symptom relief was observed to be within 3 days. Chronic conditions such as psoriasis required 2 weeks to 3 months. The findings related to practices domain have been presented in Table 2 . Symptom relapse after stopping the medication was observed in 32% of patients. Around 52% of patients receiving steroids for tinea reported relapse of symptoms immediately after stopping the use of the steroid. Out of 400 patients, 96 patients reported experiencing side effects following application of topical steroids and 71% (68/96) were from the externally prescribed group. The most common side effects i.e., exacerbation of lesions; was reported by patients using topical steroids for tinea. Other side effects were hypopigmentation, atrophy, acne, and steroid-dependent red face syndrome. Fifty-nine patients reported that they were provided inadequate instructions regarding the application of topical steroids. Out of these, 7 were not given clear instructions regarding the frequency of application and 52 were not told about the quantity and manner in which topical steroids were to be applied.

Analysis of favourable responses to practices domain of the questionnaire

The data of both groups for the variables duration and frequency has been represented in a combined manner. Out of 400 patients, 135 had been using topical steroids for more than 6 months. The results for the duration of use have been given in Figure 1 .

Duration of use of topical steroids

Regarding the pattern of use, 292 (of 400) patients said they use steroids continuously and 108 patients reported intermittent use of steroids. Among the externally prescribed patients, only 43.1% (72/167) had been prescribed by dermatologists. The distribution regarding prescribers has been given in Figure 2 .

Type of prescriber

Among the 400 patients, 159 reported once-daily application, 224 reported twice daily application whereas the remaining 17 reported thrice daily application of topical steroids. The quantification of drug applied was difficult to perform as the finger-tip unit was not used in clinical practice by prescribers. Hence, it could not be evaluated.

Clobetasol was the most common steroid prescribed accounting for 50.75% of the prescriptions, followed by mometasone (25%), fluticasone (13.75%), betamethasone (5%), halobetasol (3.75%), beclomethasone (1.25%), and fluocinolone (0.75%).

Psoriasis was the most common indication for which steroid was prescribed followed by tinea. All the patients who were prescribed steroids for tinea belonged to the externally prescribed group. The distribution of indications has been represented in Figure 3 . Other indications included acne (4), melasma (3), scabies (1), alopecia (1), and acanthosis (1) in the externally prescribed group and contact dermatitis (4), Prurigo nodularis (2), and atopic dermatitis (2) in the institutional group.

Indications for prescription of topical steroids

Out of 400 patients, 191 received steroid fixed-dose combinations (FDC) [ Figure 4 ]. The most commonly prescribed formulations of topical steroids were creams in 310 patients followed by ointments (80) and lotions (10). Ultrahigh potency steroids were prescribed to 234 patients, moderate-to-potent steroids to 146 patients whereas 20 patients received low-potency steroids.

Fixed-dose combinations containing topical steroids

Steroid abuse has become a growing concern amounting to a large proportion of dermatology clinic visits. The analysis of the questionnaire in this study revealed a lack of knowledge in terms of the type of drug being used by the patients and the indication for using the same. Only 5.5% of patients were aware that they were using a topical steroid. Moreover, more than half of the patients were not even aware of the indication for which they were being prescribed the medication. Less than 6% knew that steroid use is associated with side effects. The steroids in some cases had been either self-prescribed or prescribed by friends or family. The practices followed regarding the use of steroids highlighted the extent of misuse in the community. The glaring finding was that tinea was a common indication for using topical steroids in the community. Despite the heavy patient load, institutional practices were found to be better than those of the externally prescribed patients.

A major concern for dermatologists in recent years has been unscrupulous selling by chemists without prescriptions. Our study revealed that more than one-third of the patients had obtained topical steroids without a prescription while close to one-eighth had reused old prescriptions. Over the counter use of topical steroids was significantly higher in the externally prescribed patients, compared to the institutionally prescribed patients since they were not aware of the need for a prescription to procure steroids. Sinha et al . reported that 80% of people had obtained steroids over the counter while only 4% had consulted dermatologists.[ 12 ] Balasubramanian et al . also reported a high prevalence of over the counter use of topical steroids.[ 13 ]

Out of all the topical steroids, only clobetasol propionate, clobetasone 17-butyrate, fluticasone propionate, and mometasone furoate were included in Schedule H. The remaining have not been mentioned. A note at the bottom of this list states that topically applied drugs do not come under the category of Schedule H. This creates confusion leading to difficulty in interpretation of the data from Schedule H.[ 14 ] Therefore, there is a need to have better clarity on the prescription category of topical steroids in Schedule H.

Topical steroids or steroid-containing antifungal creams are commonly misused for fungal infections particularly in developing countries like India owing to their unregulated sales. Topical steroids may alleviate the symptoms such as itching but do not eliminate the fungus from the skin surface and also leads to antifungal drug resistance.[ 15 ] In our study, among the externally prescribed, the commonest indication for the use of topical steroids was tinea. These patients reported relapse of lesions after few days of steroid application which occurs due to continuous fungal proliferation. Besides, some patients developed tinea incognito and acne. Mahar et al .[ 16 ] also reported fungal infections to be the most common cause for the use of topical steroids followed by acne and skin lightening.

The most commonly prescribed steroid in our study was clobetasol (ultrahigh potency) followed by mometasone cream (moderate potency). A study revealed that four of the five top-selling creams across all segments in India contained clobetasol propionate.[ 17 ] Our study showed that more than half the patients had been using ultrahigh potency steroids whereas the rest used moderate-to-high potency steroids. More than half of the externally prescribed patients received ultrahigh potency steroids for tinea. In the study by Mishra et al .,[ 18 ] patients prescribed potent steroids by non-dermatologists suffered more adverse reactions than those prescribed by dermatologists. The authors attributed this to the lack of knowledge about potency and indications for using steroids, on the part of non-dermatologists. In our study, it was observed that of all the patients prescribed topical steroids for tinea, 60% had been prescribed by general practitioners. This shows that probably these physicians were prescribing steroids even in case of unclear diagnosis, contributing to the steroid misuse. Nagesh et al .,[ 8 ] reported that almost half the patients in their study were advised to use topical steroids by pharmacists, friends, and relatives. The authors claimed that most of the time, general practitioners and doctors from alternative medicine had prescribed these medicines. Our observations are in accordance with these findings.

Our study also showed ultrahigh potency steroids being prescribed by general practitioners, for conditions like tinea. Recently, there has also been a misleading trend to use steroids of mid and strong potency for beautification and in the form of fairness creams. Studies have reported irrational use of steroids for fairness and melasma,[ 19 , 20 , 21 , 22 ] although lesser use for these indications was observed in our study.

According to a study, the total annual sale of steroid creams in India is USD$329 million. Furthermore, 87% of the topical steroid sales were in the form of FDC's. Of these, 70% FDCs contained a topical steroid and antifungal.[ 17 ] Our study supports these findings as we observed that 47.75% of prescriptions contained FDCs. According to our study, the most common FDC used was salicylic acid with steroid, which is a rational indication for use. The most common FDC according to Verma et al . is clobetasol propionate, ornidazole, ofloxacin, and terbinafine,[ 14 ] which was same as the most common antimicrobial-steroid combination used in our study. The Drug Controller General of India (DCGI) and Ministry of Health and Family Welfare of the Government of India had issued through a gazette notification in 2016, that certain fixed-dose combinations (FDC) of topical steroids along with antibiotics drugs had no therapeutic justification and prohibited their manufacture with immediate effect.[ 23 ] As per the recent Central Drugs Standard Control Organization (CDSCO) notification of 2018, among 328 FDCs which have been banned by the DCGI, there are 12 topical steroid FDCs along with antibiotics which have been banned.[ 24 ] We found that one of these (clobetasol propionate, ornidazole, ofloxacin, and terbinafine) was commonly used by externally prescribed patients in our study for tinea. Institutional prescribing practices were found to be better as none of the patients was given topical steroids or FDCs for tinea or in absence of valid indications.

In our study, 24% of the patients reported adverse effects due to steroids. The institutional patients reported significantly lesser side effects compared to the externally prescribed group. The study by Nagesh et al .,[ 8 ] reported side effects in more than half the patients using topical steroids. The knowledge regarding side effects associated with the use of steroids was lacking in both the groups of patients in our study. Our study revealed the practice of abrupt stoppage of steroids by patients after their symptoms got relieved. The practice was significantly higher in the externally prescribed patients. These observations highlight the need to improve awareness of patients, as it is one of the important contributing reasons for steroid misuse.

The misuse of topical steroids in the community is increasing and steps need to be taken at every level to curb the problem. The precautions to be taken while using steroids and practices of using steroids were poor among externally prescribed patients as compared to institutional patients. The fact that 57% of externally prescribed prescriptions were by non-dermatologists might have contributed to the inadequate information being given to the patients. The comparison of prevailing in-house practices with prescriptions from the community helped us to give specific recommendations to our dermatology department.

There have been efforts at a national level by Indian Association of Dermatologists, Venereologists and Leprologists (IADVL). A Taskforce Against Topical Steroid Abuse (ITATSA) by IADVL has submitted an online petition to the Ministry of Health and Family Welfare, Government of India, and CDSCO to look into the issues related to the indiscriminate over the counter sale of topical steroids in India.[ 24 ]

Conclusions

The present study highlights the extent of misuse of topical steroids in the community especially with respect to fungal infections and also indicates an overall lack of awareness about the type of drug and side effects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for their clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Is a robot writing your kids’ essays? We asked educators to weigh in on the growing role of AI in classrooms.

Educators weigh in on the growing role of ai and chatgpt in classrooms..

Remember writing essays in high school? Chances are you had to look up stuff in an encyclopedia — an actual one, not Wikipedia — or else connect to AOL via a modem bigger than your parents’ Taurus station wagon.

Now, of course, there’s artificial intelligence. According to new research from Pew, about 1 in 5 US teens who’ve heard of ChatGPT have used it for schoolwork. Kids in upper grades are more apt to have used the chatbot: About a quarter of 11th- and 12th-graders who know about ChatGPT have tried it.

For the uninitiated, ChatGPT arrived on the scene in late 2022, and educators continue to grapple with the ethics surrounding its growing popularity. Essentially, it generates free, human-like responses based on commands. (I’m sure this sentence will look antiquated in about six months, like when people described the internet as the “information superhighway.”)

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I used ChatGPT to plug in this prompt: “Write an essay on ‘The Scarlet Letter.’” Within moments, ChatGPT created an essay as thorough as anything I’d labored over in AP English.

Is this cheating? Is it just part of our strange new world? I talked to several educators about what they’re seeing in classrooms and how they’re monitoring it. Before you berate your child over how you wrote essays with a No. 2 pencil, here are some things to consider.

Adapting to new technology isn’t immoral. “We have to recalibrate our sense of what’s acceptable. There was a time when every teacher said: ‘Oh, it’s cheating to use Wikipedia.’ And guess what? We got used to it, we decided it’s reputable enough, and we cite Wikipedia all the time,” says Noah Giansiracusa, an associate math professor at Bentley University who hosts the podcast “ AI in Academia: Navigating the Future .”

“There’s a calibration period where a technology is new and untested. It’s good to be cautious and to treat it with trepidation. Then, over time, the norms kind of adapt,” he says — just like new-fangled graphing calculators or the internet in days of yore.

“I think the current conversation around AI should not be centered on an issue with plagiarism. It should be centered on how AI will alter methods for learning and expressing oneself. ‘Catching’ students who use fully AI-generated products ... implies a ‘gotcha’ atmosphere,” says Jim Nagle, a history teacher at Bedford High School. “Since AI is already a huge part of our day-to-day lives, it’s no surprise our students are making it a part of their academic tool kit. Teachers and students should be at the forefront of discussions about responsible and ethical use.”

Teachers and parents could use AI to think about education at a higher level. Really, learning is about more than regurgitating information — or it should be, anyway. But regurgitation is what AI does best.

“If our system is just for students to write a bunch of essays and then grade the results? Something’s missing. We need to really talk about their purpose and what they’re getting out of this, and maybe think about different forms of assignments and grading,” Giansiracusa says.

After all, while AI aggregates and organizes ideas, the quality of its responses depends on the users’ prompts. Instead of recoiling from it, use it as a conversation-starter.

“What parents and teachers can do is to start the conversation with kids: ‘What are we trying to learn here? Is it even something that ChatGPT could answer? Why did your assignment not convince you that you need to do this thinking on your own when a tool can do it for you?’” says Houman Harouni , a lecturer on education at the Harvard Graduate School of Education.

Harouni urges parents to read an essay written by ChatGPT alongside their student. Was it good? What could be done better? Did it feel like a short cut?

“What they’re going to remember is that you had that conversation with them; that someone thought, at some point in their lives, that taking a shortcut is not the best way ... especially if you do it with the tool right in front of you, because you have something real to talk about,” he says.

Harouni hopes teachers think about its implications, too. Consider math: So much grunt work has been eliminated by calculators and computers. Yet kids are still tested as in days of old, when perhaps they could expand their learning to be assessed in ways that are more personal and human-centric, leaving the rote stuff to AI.

“We could take this moment of confusion and loss of certainty seriously, at least in some small pockets, and start thinking about what a different kind of school would look like. Five years from now, we might have the beginnings of some very interesting exploration. Five years from now, you and I might be talking about schools wherein teaching and learning is happening in a very self-directed way, in a way that’s more based on … igniting the kid’s interest and seeing where they go and supporting them to go deeper and to go wider,” Harouni says.

Teachers have the chance to offer assignments with more intentionality.

“Really think about the purpose of the assignments. Don’t just think of the outcome and the deliverable: ‘I need a student to produce a document.’ Why are we getting students to write? Why are we doing all these things in the first place? If teachers are more mindful, and maybe parents can also be more mindful, I think it pushes us away from this dangerous trap of thinking about in terms of ‘cheating,’ which, to me, is a really slippery path,” Giansiracusa says.

AI can boost confidence and reduce procrastination. Sometimes, a robot can do something better than a human, such as writing a dreaded resume and cover letter. And that’s OK; it’s useful, even.

“Often, students avoid applying to internships because they’re just overwhelmed at the thought of writing a cover letter, or they’re afraid their resume isn’t good enough. I think that tools like this can help them feel more confident. They may be more likely to do it sooner and have more organized and better applications,” says Kristin Casasanto, director of post-graduate planning at Olin College of Engineering.

Casasanto says that AI is also useful for de-stressing during interview prep.

“Students can use generative AI to plug in a job description and say, ‘Come up with a list of interview questions based on the job description,’ which will give them an idea of what may be asked, and they can even then say, ‘Here’s my resume. Give me answers to these questions based on my skills and experience.’ They’re going to really build their confidence around that,” Casasanto says.

Plus, when students use AI for basics, it frees up more time to meet with career counselors about substantive issues.

“It will help us as far as scalability. … Career services staff can then utilize our personal time in much more meaningful ways with students,” Casasanto says.

We need to remember: These kids grew up during a pandemic. We can’t expect kids to resist technology when they’ve been forced to learn in new ways since COVID hit.

“Now we’re seeing pandemic-era high school students come into college. They’ve been channeled through Google Classroom their whole career,” says Katherine Jewell, a history professor at Fitchburg State University.

“They need to have technology management and information literacy built into the curriculum,” Jewell says.

Jewell recently graded a paper on the history of college sports. It was obvious which papers were written by AI: They didn’t address the question. In her syllabus, Jewell defines plagiarism as “any attempt by a student to represent the work of another, including computers, as their own.”

This means that AI qualifies, but she also has an open mind, given students’ circumstances.

“My students want to do the right thing, for the most part. They don’t want to get away with stuff. I understand why they turned to these tools; I really do. I try to reassure them that I’m here to help them learn systems. I’m focusing much more on the learning process. I incentivize them to improve, and I acknowledge: ‘You don’t know how to do this the first time out of the gate,’” Jewell says. “I try to incentivize them so that they’re improving their confidence in their abilities, so they don’t feel the need to turn to these tools.”

Understand the forces that make kids resort to AI in the first place . Clubs, sports, homework: Kids are busy and under pressure. Why not do what’s easy?

“Kids are so overscheduled in their day-to-day lives. I think there’s so much enormous pressure on these kids, whether it’s self-inflicted, parent-inflicted, or school-culture inflicted. It’s on them to maximize their schedule. They’ve learned that AI can be a way to take an assignment that would take five hours and cut it down to one,” says a teacher at a competitive high school outside Boston who asked to remain anonymous.

Recently, this teacher says, “I got papers back that were just so robotic and so cold. I had to tell [students]: ‘I understand that you tried to use a tool to help you. I’m not going to penalize you, but what I am going to penalize you for is that you didn’t actually answer the prompt.”

Afterward, more students felt safe to come forward to say they’d used AI. This teacher hopes that age restrictions become implemented for these programs, similar to apps such as Snapchat. Educationally and developmentally, they say, high-schoolers are still finding their voice — a voice that could be easily thwarted by a robot.

“Part of high school writing is to figure out who you are, and what is your voice as a writer. And I think, developmentally, that takes all of high school to figure out,” they say.

And AI can’t replicate voice and personality — for now, at least.

Kara Baskin can be reached at [email protected] . Follow her @kcbaskin .