I thank Dr. Scott Garrison for his thoughtful comments. Statistics are not my thing so am not able to provide a sense of absolute risk.
I do think that the large cohort study by Dr. Feng-Chen Kao provides compelling evidence for the association of systemic corticosteroid use with both fracture-related arthroplasty and fracture-unrelated surgery. In a group of 21,995 users matched 1:1 with non-users followed over 12 years, the hazard ratio (HR) was double for steroid users over non-users.
The HR increased with increased steroid dosage, particularly in those with fracture-unrelated arthropathy. The adjusted HR increased from (95% CI, –) in the low-dose subgroup, (95% CI, –) in intermediate-dose users, to (95% CI, –) in the high-dose counterpart (Ptrend<).
I think the most important point is that systemic corticosteroids are not a substitute for topical corticosteroids. They are a potent, broad-spectrum immunosuppressive agent and need to be prescribed with the same cautions you would use with any other immunosuppressive agent.
Topical corticosteroids are potent immunosuppressants but with normal use, rarely cause systemic symptoms. Our skin is an excellent barrier.
I remember seeing a sixteen-year-old girl who had been prescribed clobetasol cream to treat her atopic dermatitis. It cleared her disease. However, she continued to apply it to her skin every morning after her shower to prevent the eczema from coming back.
She continued the daily treatment for a year. By that time, she had developed severe striae over her arms and legs. She was assessed by an endocrinologist and had no evidence of adrenal suppression.