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Topical Corticosteroids

Topical Corticosteroids have been extensively used over 30 years. There are a large number of topical steroids available. These quick acting topical agents are the mainstay of therapy for eczema. They are available as creams, lotions, gels and ointments. The wide spectrum of strengths and bases allows them to be used both effectively and safely by an experienced physician.

STRENGTHS OF TOPICAL CORTISONES

 

REDUCED ECZEMA FLARE-UPS

Hydrocortisone 1%
... is much weaker than

Betamethasone Valerte 0.1%
... which is weaker than

Clobetasol Propionate 0.05%

 

Mild to Moderate:

Moisturizing
Moderately potent topical corticosteroids (Eumovate)

Moderate to Severe:

Moisturizing
Twice a week application of Fluticasone propionate (potent topical corticosteriod) Br J Dermatol 2003;326:1367

They have an effect on reducing inflammation and itch. Selection of an appropriate product will also provide good moisturization of the skin.

Corticosteroid Selection Depends On Multiple Factors:

Topical Corticosteroid Strength

Type of Patient

Location and Description

Very Potent

Adult

Localized area,
Resistant thick lesion, palms, soles, scalp

Potent

Adult

Localized area,
thick lesion, palms, soles, scalp

Moderately Potent

Adult, Child

Extensive area of skin

Weak/Mildly Potent

Adult, Child, Infant

Face, folds, genitals, extensive areas of skin

Potency Classification Of Topical Corticosteriods:

Very potent:

  • Betamethasone dipropionate (Diprolene)
  • Clobetasol 17-Propionate 0.05% (Dermovate)
  • Halobetasolpropionate (Ultravate)
  • Halcinonide 0.1% (Halog)

Potent:

  • Amcinonide 0.1% (Cyclocort)
  • Betamethasone dipropionate 0.5 mg (Diprolene, generics)
  • Betamethasone valerate 0.05% (Betaderm, Celestoderm,Prevex)
  • Desoximetasone 0.25% (Desoxi,Topicort)
  • Diflucortolone valerate 0.1% (Nerisone)
  • Fluocinonlone acetonide 0.25% (Derma,Fluoderm,Synalar)
  • Fluocinonide 0.05% (Lidemol,Lidex,Tyderm,Tiamol,Topsyn)
  • Fluticasone Propionate (Cutivate)
  • Halcinonide (Halog)
  • Mometasone furoate 0.1% (Elocom)

Moderately potent:

  • Betamethasone valerate (Betnovate)
  • Betamethasone valerate (Celestoderm)
  • Clobetasone 17-Butyrate 0.05% (Eumovate)
  • Desonide 0.05% (Desocort)
  • Hydrocortisone acetate 1.0% (Cortef, Hyderm)
  • Hydrocortisone valerate 0.2% (Westcort, Hydroval)
  • Prednicarbate 0.1% (Dermatop)
  • Triamcinolone Acetonide 0.1% (Kenalog,Traiderm)

Mild:

  • Desonide (Desocort)
  • Hydrocortisone 0.5% (Cortate, Claritin, Cortoderm)
  • Hydrocortisone Acetate 0.5% (Cortef, Hyderm)

Some General Rules Prescribing Topical Corticosteroids:

Below are some general rules to remember when prescribing topical corticosteriods:

Potential Side Effects Of Topical Corticosteroids:

  • Very responsive diseases require mild or moderately potent formulations, less responsive diseases require potent or very potent formulations
  • Mild formulations only should be used on face, groin, axillae, genital and perianeal areas
  • Very potent formulations should be used for short periods of time (14-20 days) or intermittently to reduce adverse events
  • Potent or very potent formulations are usually required on palms, soles, and for lichenified and hypertrophic dermatoses
  • Brief use of a more potent steroids achieves faster control of eczema and may result in less steroid use compared with long use of inadequately potent preparations
  • Occlusion is often needed on palms and soles to enhance penetration of the active molecule through the thicker stratum corneum
  • Corticosteroids should not be used on ulcerated or atrophic skin
  • Sudden discontinuation should be avoided, after prolonged use, to prevent rebound phenomenon
  • When treating children, special guidelines should be followed to avoid the disadvantages of under-application or the occurrence of systemic or local adverse effects due to overdosage
  • Laboratory tests for adrenal suppression is performed by some after long periods of therapy and/or treatment of large areas

Local skin effects:

  • Atrophy, striae, purpura
  • Acne, perioral dermatitis, rosacea like rash
  • Increase hair growth
  • Hypopigmentation(whitening)
  • Tinea incognito (masks the appearance of fungal infections)
  • Allergic contact dermatitis to corticosteroids
  • Tachyphylaxis
  • Glaucoma and cataracts when used around eyes

Systemic side effects:

  • Growth suppression
  • Adrenal suppression
  • Most risk in infants
  • Risk if big surface area treated

Side effects are dependent on the active molecule and are generally seen with repeated or prolonged use of very potent and potent topical corticosteroids. Prolonged use of mildy or moderately potent topical corticosteroids may cause side effects.

Growth impairment can be a question when large quantities of topical steroids are used. This has to be balanced against the growth inhibiting effect of long term chronic inflammation such as is produced by the eczema itself.

Predictors Of Side Effects From Topical Corticosteroids:

Using moderate, potent or very potent steroids:

  • Too long
  • Too often
  • Too much
  • Under occlusion
  • On face, folds genitals inner thighs
  • Too young and too old
  • Too extensive an area

Tips For Minimizing Side Effects Of Topical Corticosteroids:

Use moderate, potent or very potent steroids only:

  • Only on thick lesions
  • Only for 2-3 weeks
  • Only once a day application
  • Best effect if used in the early evening
  • If maintenance required use on the weekends only
  • Maintain with weaker steroid or TIMs
  • Frequent moisturizing minimizes the need of medication.
  • Less steroids may be needed if secondary infections are treated

Corticosteroid Allergy:

Consider a topical corticosteroid allergy if an eruption that to you would have expected to improve does not. Patch tests would be required for identification.

Combination Therapy:

Topical steroids have been both extensively used and found to be very effective for the treatment of eczema. Concerns about side effects both on the skin and systemically has increased acceptance of the new steroid free alternative. Worries about long term use of a cortisone cream making the skin less responsive to treatment is a potential risk and is occasionally a concern. This may not occur with the topical immunomodulators but longer term studies will be needed to confirm this.

The new topical immunomodulators (TIMS) provide a significant new choice in the treatment of atopic eczema. They are used as a steroid-sparing medications. There is a discussion whether the immunomodulators should be used alone as monotherapy. Good evidence is available to show that using a potent topical cortisone twice a week only will reduce and may prevent eczema flares. If this was combined with intermittent use the immunomodulators this might further reduce flares. However some TIMs may reduce flares on their own.

For locations such as the face, folds and anterior upper chest the topical immunomodulators seem to be effective, well tolerated and free of significant side effects other than initial and minimal burning.

The following charts simplify some of the anti-inflammatory options:

Eczema Maintenance Options With Anti-Inflammatory

Steroids = corticosteroids
TIMS = topical immunomodulators (Protopic, Elidel)

Eczema Maintenance Options With Anti-Inflammatory

Eczema Flare-Up Options with Anti-Inflammatory

Steroids = corticosteroids
TIMS = topical immunomodulators (Protopic, Elidel)

Eczema Flare-Up Options with Anti-Inflammatory