A 38-year-old woman with moderate persistent asthma has been using inhaled fluticasone propionate 250 µg twice daily for 6 months. She now presents with hoarseness of voice and white patches in her oral cavity. What is the most common local adverse effect of inhaled corticosteroids responsible for her symptoms?

Explanation

## Most Common Local Adverse Effect of Inhaled Corticosteroids **Key Point:** Oral candidiasis is the most common local adverse effect of inhaled corticosteroids, occurring in 5–10% of patients using these agents regularly. ### Mechanism 1. ICS deposit directly on oral and pharyngeal mucosa 2. Suppress local immune function and alter normal flora 3. Candida albicans overgrowth occurs in the immunosuppressed microenvironment 4. Manifests as white plaques, erythema, and dysphagia ### Clinical Presentation The patient's combination of **hoarseness** (laryngeal involvement) and **white patches** (oral plaques) is pathognomonic for ICS-induced oral candidiasis. ### Prevention Strategies - **Rinse mouth with water** after each ICS inhalation (single most effective measure) - Use spacer devices to reduce oropharyngeal deposition - Consider antifungal mouth rinse (nystatin) if candidiasis develops - Proper inhaler technique education **High-Yield:** Oral candidiasis incidence is dose-dependent and increases significantly with higher ICS doses (>400 µg/day fluticasone equivalent). It is reversible upon discontinuation or with topical antifungal therapy. **Clinical Pearl:** The hoarseness results from laryngeal candidiasis and/or local ICS-induced vocal cord changes, not from systemic effects. ### Comparison with Other Local Effects | Adverse Effect | Incidence | Mechanism | Reversibility | |---|---|---|---| | Oral candidiasis | 5–10% | Local immunosuppression | Yes (reversible) | | Dysphonia/hoarseness | 3–5% | Laryngeal irritation + candidiasis | Yes | | Throat irritation | 2–3% | Direct mucosal irritation | Yes | | Cough | 1–2% | Airway irritation | Yes | [cite:Harrison 21e Ch 314]