Immunosuppressants – What you Need to Know

Immunosuppressant drugs are a class of drugs that suppress, or reduce, the strength of the body’s immune system.

Therapies that block parts of the immune system are sometimes given for several kinds of medical situations, including autoimmune diseases, as chemotherapy for cancer treatment they are also used to prevent organ transplant rejection, and as treatments for some severe skin conditions.

While helpful, these drugs are also very powerful. You should know all you can about them if your doctor prescribes them for you.

If your doctor has prescribed an immunosuppressant medication for you, here’s what to know about what these drugs do, how they work, and how they might make you feel.

Corticosteroids

Corticosteroids are anti-inflammatory medications that can be very effective in relieving symptoms of eczema, psoriasis and dermatitis. Corticosteroids suppress the activity of some immune cells, which can interrupt the inflammatory process and prevent itching, redness, and swelling.

Types of corticosteroids

• creams – applied to the affected areas of the skin
• tablets – dosage varies, but is generally kept to the lowest dose possible
• injections – injecting straight into the affected joint, which prevents many of the side effects that occur with oral medication

Your dermatologist determines the duration of topical corticosteroid treatment, which varies depending on factors such as the severity of flare-ups and the age of the person being treated. For severe eczema or dermatitis, topical corticosteroids may be used intermittently for months or years. Continued use requires regular evaluation by your dermatologist.

Your healthcare provider may also prescribe medicines in severe cases. The following are commonly used to treat atopic dermatitis:

• Antihistamines. These medicines are taken by mouth. They may help to ease itching. Some examples include diphenhydramine and hydroxyzine. They may cause drowsiness.
• Steroid creams. These are put on the skin to help ease inflammation, itching, and swelling. Many topical steroids are available in various strengths. If overused, they can cause skin thinning and discoloration.
• Systemic corticosteroids. These medicines ease inflammation, which can relieve itching. They are used for severe cases. They are available as a pill, liquid, or shot. These steroids have serious side effects from the long-term use. So, they are only used for a short time to stop a flare-up.
• Oral antibiotics. These medicines kill bacteria that cause infections. Scratching the affected skin can bring bacteria to the area. This can lead to infection. Always take the antibiotic exactly as prescribed until it is all gone.
• Oral cyclosporine. This medicine has been used for years to treat atopic dermatitis that doesn’t respond to other treatments. It’s available as a capsule or liquid. It has many side effects that should be considered carefully.
• Phototherapy. Two types are used to treat atopic dermatitis: ultraviolet (UV) light therapy and PUVA (chemophototherapy). Light therapy uses UV light of specific wavelengths to target the immune system. It stops the responses that lead to inflammation. Phototherapy may be used along with other treatment. There are risks and benefits of light therapy. Weigh these risks with your healthcare provider.
• Topical immunomodulator. Also known as topical calcineurin inhibitors. They are put on the skin to change the immune response.
• Methotrexate. An immunosuppressive medicine that can be used to manage atopic dermatitis long term. However, it can potentially harm the liver.
• Barrier restoration creams. Like moisturizers, but they help repair the skin as well as provide moisture.

Side Effects of Corticosteroids

People treated with corticosteroids may experience unwanted side effects. Suddenly stopping the medication can also be dangerous, so continue taking your regular dose and see your doctor if you are troubled by side effects.

Topical steroid withdrawal, sometimes referred to as ‘red skin syndrome’, can occur when frequently using or misusing moderate to high potency corticosteroids then stopping, either abruptly or reducing their dose too quickly.

Withdrawal symptoms include swelling, redness, burning, and skin sensitivity and this starts usually within 1-2 weeks of stopping the steroid.

Some of the more common side effects of cortisol-like drugs include:

• thin skin
• susceptibility to bruising
• high or increased blood pressure
• susceptibility to infections
• build-up of fat around the face, chest and abdomen
• osteoporosis (thinning of the bones) leading to bone fractures, particularly in the spine
• fluid retention (oedema)
• diabetes.

Topical Calcineurin Inhibitors

Topical calcineurin inhibitors are a type of immunosuppressant medication. They are formulated to block an overactive immune system response to the skin, which may reduce itching, redness, and swelling. Doctors typically prescribe calcineurin inhibitors when topical corticosteroids are ineffective or if eczema or dermatitis affects sensitive areas of skin that can’t be treated with topical corticosteroids for long periods.

There are two types available: tacrolimus ointment (Protopic) for moderate to severe eczema and pimecrolimus cream (Elidel) for mild to moderate eczema.

• Topical calcineurin inhibitors generally have fewer long-term side effects than corticosteroids and may be used safely for months or years. 
• Side effects may include a small risk of infection, and some people may experience a stinging sensation when the medication is first applied, but it generally fades over time.

What are the side effects of TCIs?

• Clinical trials involving TCIs have looked into potential side effects, and research is ongoing to assess the long-term side effects of this relatively new treatment.
• The main short-term side effects identified are an irritating, burning and itching feeling on the skin where TCIs are applied. This is estimated to occur in half of all people using them. These symptoms generally disappear within a week of use.
• Other side effects include changes in skin colouration (skin becoming red or darker) on the area of application, a sensation of warmth on the area of application, and ‘pins and needles’. A few people also experienced blocked skin pores (folliculitis) and viral skin infections such as cold sores and warts. In children, impetigo is more common in children using TCIs.
• Some people experience increased skin irritation and facial flushing during tacrolimus treatment.

Janus Kinase Inhibitors

Janus kinase inhibitors have shown beneficial effects in a variety of immune-mediated conditions affecting the skin, joints, and gastrointestinal tract As Janus kinase inhibitors are small molecules they can be used topically or orally. Janus kinase inhibitors are used for the treatment of:

• Atopic dermatitis
• Alopecia areata
• Vitiligo
• Plaque psoriasis
• Other dermatoses

Side effects of Janus kinase inhibitors

As Janus kinase inhibitors alter the immune response, they may be associated with increased risk of serious bacterial, fungal, mycobacterial, and viral infections. Common adverse side effects of JAK inhibitors include:

• Nasopharyngitis
• Infection of upper respiratory and urinary tracts
• Headache
• Nausea and diarrhoea

Immunosuppressant Overview

Side effects vary greatly for the many different immunosuppressant drugs available. To find out the side affects you may be at risk for, ask your doctor or pharmacist about the effects of your particular drug.

All immunosuppressant drugs carry the serious risk of infection. When an immunosuppressant drug weakens your immune system, your body becomes less resistant to infection. That means they make you more likely to get infections. It also means that any infections get will be harder to treat.

If you have any of these symptoms of infection, call your doctor right away:

• fever or chills
• pain in the side of your lower back
• trouble urinating
• pain while urinating
• frequent urination
• unusual tiredness or weakness

Warnings

Immunosuppressant drugs can cause problems for people with certain health conditions. Tell your doctor if you have any of these conditions before you start to take immunosuppressants:

• allergy to the specific drug
• history of shingles or chickenpox
• kidney or liver disease

Please be aware that Elidel and Tacrolimus are classed as immunosuppressants. Immunosuppressants suppress your immune response to an issue, so it is still possible to rebound from these creams. Please read about the FDA's Black-box warning for these medications here.

If you need topical steroid usage support or help with steroid withdrawals you can sign up to Holistic Coaching with Kiri as she has extensive knowledge on oral and topical steroid withdrawals. And there are also steroid withdrawals support groups via ITSAN.

DUPIXENT is a new injection medication. Dupixent works with your body's immune system to help reduce inflammation contributing to your eczema, which may help reduce your uncontrolled moderate-to-severe eczema (atopic dermatitis) symptoms and may give you noticeably clearer skin.

Pregnancy and breastfeeding

Some of these drugs can cause birth defects, while others carry milder risks during pregnancy and breastfeeding. In any case, if you’re planning to become pregnant, talk to your doctor before taking an immunosuppressant drug. Your doctor can tell you about the risks of the specific drug you might be taking.
If you get pregnant while taking an immunosuppressant, tell your doctor right away.

The AMPERNA^® Skin Solution

When it comes to skin health, Kiri, founder of AMPERNA^®, helps many people suffering from a variety of skin & health conditions. 

Kiri has developed a no-nasties steroid solution for skin concern.

The probiotic complex infused within AMPERNA^® products supports the skin barrier, helping to protect you from aggressions such as environmental pollutants, keep your immune system in check and reduce inflammation.

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You can book a Holistic Skin Coaching Service to discuss your skin concerns and develop a tailored plan to work towards healthy skin. 

References:

Immunosuppressant Drugs: A Complete Overview (healthline.com)

Hormones – cortisol and corticosteroids - Better Health Channel

Immunosuppressants: Definition, Treatment & What Is It (clevelandclinic.org)

Medication for Eczema & Dermatitis | NYU Langone Health

Immunosuppressants: Uses, Side Effects, Precautions (verywellhealth.com)

Eczema | Johns Hopkins Medicine

Atopic Dermatitis Medications: Main Types to Know | Everyday Health

Janus kinase inhibitors | DermNet NZ

Topical Calcineurin Inhibitors | Eczema.org