What is cortisone and how does it work in the body. How are cortisone medications administered for various conditions. What are the potential side effects and risks of cortisone use. How do corticosteroids differ from anabolic steroids.

The Nature and Function of Cortisone in the Body

Cortisone is a synthetic version of cortisol, a naturally occurring hormone produced by the adrenal glands. Both cortisone and cortisol belong to a class of hormones called glucocorticosteroids. These powerful compounds play a crucial role in regulating the body’s inflammatory and immune responses.

How does cortisone work in the body? Cortisone and its derivatives act by suppressing the immune system’s inflammatory and allergic reactions. This makes them particularly effective in treating a wide range of inflammatory conditions, including autoimmune diseases and joint disorders.

The Relationship Between Cortisone and Cortisol

While cortisone is man-made, it closely mimics the action of naturally produced cortisol. However, synthetic cortisone medications are often more potent than their natural counterparts. This increased potency allows for more effective treatment of severe inflammatory conditions.

Various Forms of Cortisone Medications

Cortisone-based medications come in several forms, each designed to treat specific conditions or meet particular medical needs. The main types include:

• Oral medications (pills or liquids)
• Injectable solutions
• Topical preparations (creams, gels, foams, sprays, and patches)
• Inhalable mists

The choice of medication form depends on the condition being treated, its severity, and the patient’s overall health status.

Oral Cortisone Medications: Uses and Considerations

Oral corticosteroids are often prescribed for systemic inflammatory disorders that affect the entire body. These conditions may include:

• Rheumatoid arthritis
• Ankylosing spondylitis
• Severe allergic reactions
• Certain lung diseases

Why are oral corticosteroids often used as initial treatment? These medications act quickly to reduce inflammation and provide relief from symptoms. They are particularly useful in managing acute flare-ups of chronic conditions.

However, long-term use of oral corticosteroids can lead to significant side effects. For this reason, they are typically prescribed for short periods or as a bridge therapy while other, slower-acting medications take effect.

The Importance of Proper Tapering

When discontinuing oral corticosteroid therapy, it’s crucial to taper the dose gradually under medical supervision. Abrupt cessation can lead to withdrawal symptoms and potentially dangerous health complications.

Topical Cortisone Preparations: Treating Skin Conditions

Topical corticosteroids are widely used to treat various skin inflammations and allergic reactions. These may include:

• Eczema
• Psoriasis
• Contact dermatitis
• Insect bites
• Poison ivy reactions

Are all topical corticosteroids the same strength? No, they range from mild over-the-counter hydrocortisone creams to potent prescription-only preparations. The strength of the medication should match the severity of the condition being treated.

Cortisone Mists for Respiratory Conditions

Inhalable cortisone mists are commonly used to treat inflammatory respiratory conditions such as:

• Asthma
• Chronic obstructive pulmonary disease (COPD)
• Allergic rhinitis
• Sinusitis

These medications deliver the corticosteroid directly to the airways, reducing inflammation and improving breathing.

Cortisone Injections: Targeted Treatment for Joint and Soft Tissue Inflammation

Cortisone injections are a powerful tool in treating localized inflammation, particularly in joints and soft tissues. They are commonly used for conditions such as:

• Osteoarthritis
• Rheumatoid arthritis
• Bursitis
• Tendonitis
• Gout

How do cortisone injections work? By delivering a potent anti-inflammatory medication directly to the affected area, these injections can provide rapid relief from pain and swelling.

Common Scenarios for Cortisone Injections

Physicians may recommend cortisone injections in various situations, including:

• Severe gout flare-ups affecting mobility
• Following joint fluid aspiration to prevent symptom recurrence
• Persistent single-joint swelling in rheumatoid arthritis
• When other non-surgical treatments for osteoarthritis or tendonitis have failed

While effective, cortisone injections are typically used judiciously due to potential side effects associated with repeated use.

Potential Risks and Side Effects of Cortisone Use

While cortisone medications can be highly effective, they also carry the risk of side effects, particularly with long-term or high-dose use. These may include:

• Weight gain
• Osteoporosis
• Increased blood sugar levels
• Skin thinning and easy bruising
• Increased susceptibility to infections
• Mood changes
• Cataracts and glaucoma

The risk and severity of side effects often depend on the dosage, duration of use, and individual patient factors. Healthcare providers carefully weigh the benefits against potential risks when prescribing cortisone medications.

Special Considerations for Topical Cortisone Use

Topical corticosteroids can cause local side effects such as skin thinning, stretch marks, and increased hair growth at the application site. Prolonged use on large areas of skin may also lead to systemic effects similar to those of oral corticosteroids.

Corticosteroids vs. Anabolic Steroids: Understanding the Difference

It’s crucial to distinguish between corticosteroids like cortisone and anabolic steroids. While they share similar chemical structures, their functions and effects on the body are vastly different.

How do corticosteroids and anabolic steroids differ?

• Corticosteroids are used to treat inflammation and autoimmune conditions
• Anabolic steroids are synthetic substances related to testosterone, used to enhance muscle growth and athletic performance
• Corticosteroids suppress the immune system, while anabolic steroids do not
• Anabolic steroids are often abused for non-medical purposes, which can lead to severe health problems

Understanding this distinction is important for patients and healthcare providers alike to ensure proper use and avoid confusion.

The Role of Cortisone in Managing Chronic Inflammatory Conditions

For many patients with chronic inflammatory diseases, cortisone-based medications play a crucial role in managing symptoms and preventing disease progression. These conditions may include:

• Rheumatoid arthritis
• Lupus
• Inflammatory bowel diseases
• Asthma
• Multiple sclerosis

How does cortisone help in managing these conditions? By suppressing the overactive immune response that causes inflammation, cortisone can reduce pain, swelling, and other symptoms associated with these diseases.

Cortisone as Part of a Comprehensive Treatment Plan

While cortisone can be highly effective, it’s often used in conjunction with other treatments. For example, in rheumatoid arthritis, cortisone might be used alongside disease-modifying antirheumatic drugs (DMARDs) or biologic medications. This multi-faceted approach aims to control symptoms while also addressing the underlying disease process.

Optimizing Cortisone Treatment: Best Practices and Considerations

To maximize the benefits of cortisone treatment while minimizing risks, healthcare providers and patients should consider several factors:

• Using the lowest effective dose for the shortest necessary duration
• Regular monitoring for side effects and adjusting treatment as needed
• Combining cortisone with other treatments to reduce reliance on corticosteroids
• Implementing lifestyle changes to support overall health and potentially reduce the need for medication
• Proper education on medication use, potential side effects, and when to seek medical attention

What steps can patients take to ensure safe and effective cortisone use? Open communication with healthcare providers, adherence to prescribed regimens, and reporting any unusual symptoms or side effects are crucial for optimal treatment outcomes.

The Importance of Individualized Treatment Plans

Every patient’s response to cortisone can be different, and what works well for one person may not be ideal for another. Factors such as age, overall health status, other medications, and specific disease characteristics all play a role in determining the most appropriate treatment approach.

Healthcare providers work closely with patients to develop personalized treatment plans that balance the benefits of cortisone therapy with potential risks, taking into account individual needs and preferences.

Future Directions in Cortisone Research and Development

As medical science advances, researchers continue to explore ways to improve cortisone-based treatments and develop alternatives with fewer side effects. Some areas of ongoing research include:

• Development of more targeted corticosteroids with reduced systemic effects
• Exploration of novel drug delivery methods to enhance efficacy and minimize side effects
• Investigation of combination therapies that may allow for lower cortisone doses
• Research into the long-term effects of different cortisone treatment regimens
• Studies on genetic factors that influence individual responses to cortisone therapy

How might these advances impact future cortisone treatments? As our understanding of inflammation and immune responses grows, we may see more personalized and effective approaches to using cortisone and related medications, potentially offering better outcomes with fewer risks for patients with inflammatory conditions.

The Promise of Precision Medicine

The field of precision medicine holds particular promise for optimizing cortisone treatments. By analyzing genetic and molecular markers, healthcare providers may be able to predict which patients are most likely to benefit from cortisone therapy and who might be at higher risk for side effects. This could lead to more tailored treatment plans and improved patient outcomes.

As research progresses, patients and healthcare providers can look forward to potentially more effective and safer ways to harness the powerful anti-inflammatory properties of cortisone and related compounds.

What Is Cortisone? | Arthritis-health

A valuable tool in treating inflammation, cortisone is a man-made version of a natural hormone called cortisol. Cortisone is used to treat inflammatory conditions such as autoimmune diseases as well as joint swelling and pain.

Cortisone injections are a common treatment for knee osteoarthritis. See Knee Osteoarthritis Treatment

Both man-made cortisone and cortisol produced in the body are types of glucocorticosteroids. The terms glucocorticosteroids, corticosteroids, cortisone, and cortisol may be used interchangeably.

• Cortisol is produced by the body’s adrenal glands. In large quantities, cortisol suppresses the immune system’s inflammatory and allergic responses.
• Cortisone medications mimic the action of cortisol but tend to be more powerful.

Corticosteroid medications come in a range of strengths. They also come in different forms, such as pills, liquids that can be injected directly into the body, and topical creams that can be applied to the skin.

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Oral Cortisone Medications

People who have inflammatory disorders that affect the entire body, such as rheumatoid arthritis and ankylosing spondylitis, may treat painful flare-ups with oral corticosteroids, such as prednisone and methylprednisolone.

• Oral corticosteroids are fast-acting and often prescribed to newly diagnosed patients to help get their inflammation under control.
• Other medications, such as disease-modifying antirheumatic drugs (DMARDs) and biologics, are typically also prescribed but can take several weeks to work.
• Chronic oral steroid use can lead to complications. Doctors typically recommend tapering their use once the DMARDs, biologics, or other medications take effect.

See Biologics: Basic Facts for Patients

To avoid negative side effects, oral steroid use should be tapered under the guidance of a health care provider.

Topical Cortisone Medications

Skin inflammation may be treated with topical steroid medications, including creams, gels, foams, sprays, and patches.

• Over-the-counter hydrocortisone cream (e.g. Hydrocone-10) to treat bug bites and poison ivy.
• More powerful topical corticosteroids may be prescribed to treat conditions such as psoriasis, an inflammatory skin disorder associated with psoriatic arthritis.
• There are also cortisone mists, which are used to treat conditions such as asthma and sinusitis.

See Topical Pain Relief for Arthritis

Like oral corticosteroids, topical cortisone products can cause side effects. A doctor or pharmacist can talk to a patient about potential risks and side effects.

Cortisone Injections

Arthritic conditions can cause a joint to become inflamed, painful, and swollen. If the inflammation is chronic or is severely painful, a physician may recommend a cortisone injection. For example, cortisone may be used:

• During a gout flare-up that causes a toe to become so inflamed it is difficult to walk or bear weight on the foot
• Following the aspiration (draining of fluid) of an inflamed bursa, to help ensure bursitis symptoms go away and do not become chronic
• When rheumatoid arthritis causes persistent swelling in a single joint
• If osteoarthritis or tendonitis causes pain in a joint, and it cannot be successfully treated with other non-surgical methods

See Cortisone Injections (Steroid Injections)

An injection delivers potent medicine directly to the area of inflammation. Two examples of injectable cortisone are triamcinolone and betamethasone, each of which is sold under different brand names.

See Cortisone Injection Risks and Side Effects

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Corticosteroids Are Not the Same As Anabolic Steroids

Corticosteroids are different from anabolic steroids (such as testosterone) that are used to enhance male characteristics and improve athletic performance. Corticosteroids and anabolic steroids share similar chemical structures but play different roles in the body.

Dr. Emmanuel Konstantakos is an orthopedic surgeon specializing in sports medicine, arthroscopic surgery, and general orthopedics. Dr. Konstantakos has authored numerous research articles published in academic journals.

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Editor’s Top Picks

• Cortisone Injections (Steroid Injections)

• What to Know Before Getting a Cortisone Injection

• Cortisone Injection Procedure

• Cortisone Injection Risks and Side Effects

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What to Know Before Getting a Cortisone Injection

While cortisone injections can be an important tool in treating joint inflammation and pain, they do have limitations. Many of these limitations are described below.

Cortisone is a synthetic version of cortisol, a steroid produced by the body’s adrenal glands. Read What Is Cortisone?

A Cortisone Injection Is Part of a Larger Treatment Plan

These injections provide temporary relief. Patients who are seeking long-term relief are typically advised to:

1. Participate in physical therapy. Stretching and strengthening muscles and other soft tissues help relieve pain and other arthritis symptoms. In fact, one study

   ¹
   Deyle GD, Allen CS, Allison SC, Gill NW, Hando BR, Petersen EJ, Dusenberry DI, Rhon DI. Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee. N Engl J Med. 2020 Apr 9;382(15):1420-1429. doi: 10.1056/NEJMoa1905877. PubMed PMID: 32268027
   comparing cortisone injections to physical therapy reported that physical therapy provided better long-term relief.

   See Ways to Get Exercise When You Have Arthritis

2. Lose excess weight. Shedding excess pounds can reduce stress on a joint. Another reason to lose excess weight: cortisone injections may be less effective in relieving knee osteoarthritis pain in patients who are obese.

   ²
   Matzkin EG, Curry EJ, Kong Q, Rogers MJ, Henry M, Smith EL. Efficacy and Treatment Response of Intra-articular Corticosteroid Injections in Patients With Symptomatic Knee Osteoarthritis. J Am Acad Orthop Surg. 2017 Oct;25(10):703-714. doi: 10.5435/JAAOS-D-16-00541. PubMed PMID: 28953085.

3. Make lifestyle changes. Simple changes, such as changing footwear, can reduce the number of micro-traumas a joint experiences daily.

These steps can improve a joint’s biomechanics and possibly decrease or eliminate the need for additional cortisone shots.

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Without other treatments, joint pain will probably worsen over time
Patients who have repeated cortisone shots may notice that the period of pain relief becomes shorter and shorter over time. This is not necessarily because the patient has built up a tolerance to the medication but because the joint is degrading. Again, physical therapy, weight loss, and changes in day-to-day lifestyle can help slow down or stop joint degradation.

Activity Should Be Increased Gradually

It may take a few days for the benefits of the cortisone medication to take full effect. During this time, patients are usually told to rest and cut back on normal activities.

Once the joint pain is relieved, a well-intentioned patient may be tempted to jump right into an exercise routine. However, in order to avoid injuries or possibly making the condition worse, a doctor typically advises a patient to resume normal activities gradually and add intensity over time.

See Exercising with Arthritis

In This Article:

• Cortisone Injections (Steroid Injections)

• What to Know Before Getting a Cortisone Injection

• Cortisone Injection Procedure

• Cortisone Injection Risks and Side Effects

Repeated Injections Can Affect Soft Tissue

Too many injections over a short period of time can cause damage to the tendons, ligaments, and articular cartilage at the injection site.

³
McAlindon TE, LaValley MP, Harvey WF, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2017;317(19):1967–1975. doi:10.1001/jama.2017.5283
For this reason:

• If more than one injection must be given in the same joint, they should be spaced several weeks apart.

  ⁴
  Cardone DA, Tallia AF. Joint and soft tissue injection. Am Fam Physician. 2002 Jul 15;66(2):283-8. PubMed PMID: 12152964.
  Many doctors prefer waiting longer—at least 3 to 4 months.

  ⁵
  Martin SD, Conaway WK, Lei P. Use of Intra-Articular Corticosteroids in Orthopaedics. J Bone Joint Surg Am. 2018 May 16;100(10):885-891. doi: 10.2106/JBJS.17.00289. PubMed PMID: 29762289.

• Patients are advised to have no more than 3 or 4 injections in the same place per year.

  ⁴
  Cardone DA, Tallia AF. Joint and soft tissue injection. Am Fam Physician. 2002 Jul 15;66(2):283-8. PubMed PMID: 12152964.

• A surgeon will typically require a 3-month waiting period after a cortisone injection before operating on the affected joint.

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Tendons are particularly prone to degeneration and injury after a cortisone injection. Because of this risk, a doctor will not inject cortisone medication directly into a tendon, even if a tendon is suspected to be the root of the pain. Because cortisone works locally, an injected placed near a tendon can still reduce its inflammation.

In fact, the Achilles and patella tendons are particularly prone to injury post-injection, even if an injection is directed near, rather than in, the tendon. For this reason, doctors avoid cortisone injections for Achilles and patella tendinopathies.

⁴
Cardone DA, Tallia AF. Joint and soft tissue injection. Am Fam Physician. 2002 Jul 15;66(2):283-8. PubMed PMID: 12152964.

Dr. Emmanuel Konstantakos is an orthopedic surgeon specializing in sports medicine, arthroscopic surgery, and general orthopedics. Dr. Konstantakos has authored numerous research articles published in academic journals.

• 1
  Deyle GD, Allen CS, Allison SC, Gill NW, Hando BR, Petersen EJ, Dusenberry DI, Rhon DI. Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee. N Engl J Med. 2020 Apr 9;382(15):1420-1429. doi: 10.1056/NEJMoa1905877. PubMed PMID: 32268027
• 2
  Matzkin EG, Curry EJ, Kong Q, Rogers MJ, Henry M, Smith EL. Efficacy and Treatment Response of Intra-articular Corticosteroid Injections in Patients With Symptomatic Knee Osteoarthritis. J Am Acad Orthop Surg. 2017 Oct;25(10):703-714. doi: 10.5435/JAAOS-D-16-00541. PubMed PMID: 28953085.
• 3
  McAlindon TE, LaValley MP, Harvey WF, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2017;317(19):1967–1975. doi:10.1001/jama.2017.5283
• 4
  Cardone DA, Tallia AF. Joint and soft tissue injection. Am Fam Physician. 2002 Jul 15;66(2):283-8. PubMed PMID: 12152964.
• 5
  Martin SD, Conaway WK, Lei P. Use of Intra-Articular Corticosteroids in Orthopaedics. J Bone Joint Surg Am. 2018 May 16;100(10):885-891. doi: 10.2106/JBJS.17.00289. PubMed PMID: 29762289.

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• Share on Pinterest
• Share on Twitter
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• Email this article

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Editor’s Top Picks

• Therapeutic Injections for Knee Arthritis

• Stem Cell Therapy for Arthritis

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• Injections for Hip Osteoarthritis Video

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CORTISOL AND ITS RELATION TO IMMUNE REACTIONS

Cortisol and Allergies

Allergy is certainly a subject of immunology, because it is associated with hypersensitivity of the immune system. Immunity refers to the immunity of the body to antigens (foreign pathogens, infectious agents).

Glucocorticoids affect the immune system by inhibiting the phagocytic activity of lymphocytes and reducing their number in the blood. Therefore, synthetic analogues of cortisol are used to treat allergic diseases, as they can have anti-allergic and anti-inflammatory effects.

Mechanism of origin of allergic reactions

Allergic reactions can be immediate (E-dependent) and immunocytotoxic. An important role in the formation of an allergic reaction is played by mast cells, which are found in large numbers in the nasal cavity, upper and lower respiratory tract, and also in the skin. Mast cells have special receptors on their surface, with which they can bind to immunoglobulins E. When allergen molecules interact with immunoglobulin E antibodies, special substances – mediators – begin to be released from mast cell granules.

The first of them was discovered by scientists histamine (probably even people far from the world of medicine are familiar with the term “antihistamine drug” – a drug that suppresses allergic reactions). A consequence of the activity of mast cells is also the release of arachidonic acid, a precursor of prostaglandins and leukotrienes. Prostaglandins are active biological substances that are formed from fatty acids, they affect blood circulation, lung function, and regulate cell metabolism.

The most common allergic diseases are:

• allergic rhinitis – allergic disease of the nasal cavity
• bronchial asthma – allergic disease of the lower respiratory tract
• allergic dermatitis – allergic skin lesions

The best known synthetic analogues of cortisol are dexamethasone and prednisolone. They are an effective remedy against allergic diseases, as they have the ability to suppress the immune system. How are cortisol and the immune system related?

Glucocorticoids. Cortisol and the immune system.

Immunity can be innate (for example, all people are immune to canine distemper) and acquired (after scarlet fever, the chance of getting sick again is negligible). Acquired immunity can be natural (after an illness) or artificial (after a vaccine). Allergy is an immune reaction in which the human body produces immunoglobulins E, which serve as antibodies to certain proteins.

The main cells of the immune system are leukocytes.

A person is surrounded by a huge number of adverse factors – without protection mechanisms, he simply could not resist the huge variety of viruses, bacteria and protozoa attacking his body. The human immune system protects the body from diseases by detecting and destroying potentially threatening substances.

Immunity is an integral system of protecting the body from various diseases and adverse environmental factors.

Adverse environmental factors:

• Bacteria
• Viruses
• Protozoa
• Somatic mutations: malignant transformation

Despite the fact that all these factors are very far from each other and have different origins, they have one thing in common – they are all genetically alien to the human body. Substances that threaten a person in science are called antigens. Antigen – a substance of a certain structure that is potentially dangerous for the body.

Main organs of the immune system:

• Bone marrow
• Spleen
• Lymph nodes
• Thymus (thymus gland)

Lymphocytes are one of the varieties of leukocytes, the main cells of the immune system. The main function of lymphocytes is participation in the work of immunity. We can safely say that lymphocytes form the backbone of the human immune system, because they are its defenders, destroying foreign structures.

In the course of evolution, a universal mechanism for protecting a person from harmful environmental factors was formed – immunity. The main cells of the immune system are lymphocytes (one of the types of white blood cells).

Immune system functions:

• Recognition of foreign agents
• Neutralizing them with special protective proteins

A change in the number of lymphocytes in the blood indicates the beginning of an inflammatory process – the body fights the “invader” by increasing the number of lymphocytes. Lymphocytes synthesize protective proteins-antibodies that are involved in providing immunity.

Antibodies are protective immunoglobulin proteins (lgG, lgM, lgA, lgD, lgE). Antibodies are produced by B-lymphocytes. In addition to immunoglobulins, the immune system also activates other biological substances: interferons, lysozyme, etc.

The main thing in the development of inflammation is phagocytosis, which is carried out by lymphocytes (biological theory of II Mechnikov). Cortisol has the property of suppressing immune responses by reducing phagocytosis, as a result of which the formation of protective antibodies slows down.

Cortisol properties:

• suppresses cellular and humoral immunity
• reduces the number of lymphocytes in the blood, thereby helping to mitigate the allergic reaction and relieve inflammation.

These properties of cortisol are widely used in the pharmaceutical industry in the manufacture of topical ointments (synthetic analogues of cortisol are hydrocortisone and dexamethasone.)

Allergy is figuratively called hypersensitivity of the immune system . Since cortisol has a depressant effect on the immune system, it also affects the production of IgE immunoglobulin, which is responsible for immediate allergic reactions and blocks the inflammation process during an allergic reaction. Synthetic analogues of cortisol are an effective means of combating allergic diseases (bronchial asthma, allergic dermatitis).

antihistamines and cortisone, how to use them correctly

However, antihistamines and cortisone are drugs with a certain degree of invasiveness.

As a result, they can be harmful, both directly and through side effects, if used incorrectly.

How do antihistamines work?

Antihistamines are drugs used to treat allergy symptoms by counteracting the action of histamine receptors, a substance released by immune system cells when the body comes into contact with common allergens such as dust mites, pollen, and food.

Antihistamines, taken as nasal sprays, eye drops, capsules, tablets, and creams, are ideal for controlling common reactions such as itching, swelling, runny nose, nasal congestion, sneezing, watery eyes, and hives.

How do corticosteroids work?

Cortisone drugs are drugs used for anti-inflammatory and immunosuppressive treatment of allergy symptoms.

These drugs modify the body’s response to immune stimuli, taking effect within a short time, and are therefore suitable for acute allergy attacks. The physician must carefully evaluate the benefit / risk ratio in relation to undesirable effects.

Antihistamines and cortisone side effects

Antihistamines and corticosteroids should always be taken in the order and dosage recommended by your doctor to minimize side effects.

First generation antihistamines (currently used mainly in hospitals) have several side effects such as:

• drowsiness and decreased alertness and concentration
• insomnia, nervousness, anxiety
• increased appetite, urinary retention, constipation.

In contrast, second-generation antihistamines are less active on the central nervous system and have almost no side effects, but their use is associated with an increased risk of cardiac arrhythmias.

On the other hand, the undesirable effects of corticosteroids are mainly associated with their use, since over time they can cause:

• pimples, redness and skin changes
• weight gain and edema due to water retention
• hyperglycemia and high blood pressure
• osteoporosis and muscle weakness.