Systemic glucocorticoid use and early-onset basal cell carcinoma

Abstract

Immunosuppressive medications are common in the management of numerous conditions, such as organ transplantation, allergies, and respiratory disorders [1]. In some patients with conditions, such as organ transplantation, that require long-term, high-dose immunosuppression, immunosuppressives increase risk for squamous cell carcinoma of the skin (SCC) (60–250 fold increase), and to a lesser extent for basal cell carcinoma (BCC) (10 fold increase) [2–10]. An increased risk of non-melanoma skin cancer (NMSC) has also been associated with immunosuppressives among rheumatoid arthritis and inflammatory bowel disease patients [11–13]. With widespread use of low-potency, low-dose immunosuppressives, particularly glucocorticoids, for allergic and inflammatory conditions, there is interest in whether these low-level exposures increase NMSC risk. Glucocorticoids and NMSC have been evaluated in three studies [14–17]. A US case-control study found a two-fold increased risk of SCC with oral glucocorticoids, but only a suggestive non-significant association for BCC [16]. A Danish cohort study using national prescription data found a 16% increase in BCC with injected or oral glucocorticoids, with greater risk with more prescriptions [17]. A case-control study in the same Danish population found a 15% increase in BCC with oral glucocorticoids and increased risk with longer duration [15]. There was one positive [17] and one null finding [15] for SCC in the Danish studies. Finally, a US prospective study found no association between oral prednisone and BCC or SCC in adults with prior NMSC [14]. While short-term steroid use is not known to have any lasting impact on immune function, transient immune suppression from systemic steroid use could impact BCC risk, especially in those with high ultraviolet radiation exposure, which may itself induce local immune suppression [18]. To address the paucity of research on systemic glucocorticoids and NMSC, we evaluated this relationship in a case-control study of early-onset BCC.