Choosing Topical CorticosteroidsTopical corticosteroids fluorinated corticosteroids one of the oldest and steroids use by athletes useful treatments for dermatologic conditions. There are many topical steroids available, and they differ in potency and formulation. Although use of topical steroids is common, evidence of effectiveness exists only for select conditions, such as psoriasis, vitiligo, eczema, atopic dermatitis, phimosis, acute radiation dermatitis, and lichen sclerosus. Evidence is limited for use in melasma, chronic fluorinated corticosteroids urticaria, and alopecia areata. Topical steroids are available in a variety of potencies and preparations.
Choosing Topical Corticosteroids - American Family Physician
Topical corticosteroids are one of the oldest and most useful treatments for dermatologic conditions. There are many topical steroids available, and they differ in potency and formulation.
Although use of topical steroids is common, evidence of effectiveness exists only for select conditions, such as psoriasis, vitiligo, eczema, atopic dermatitis, phimosis, acute radiation dermatitis, and lichen sclerosus. Evidence is limited for use in melasma, chronic idiopathic urticaria, and alopecia areata. Topical steroids are available in a variety of potencies and preparations. Physicians should become familiar with one or two agents in each category of potency to safely and effectively treat steroid-responsive skin conditions.
When prescribing topical steroids, it is important to consider the diagnosis as well as steroid potency, delivery vehicle, frequency of administration, duration of treatment, and side effects. The usefulness and side effects of topical steroids are a direct result of their anti-inflammatory properties, although no single agent has been proven to have the best benefit-to-risk ratio.
Topical steroids can be used to treat psoriasis, vitiligo, lichen sclerosus, atopic dermatitis, eczema, and acute radiation dermatitis. Ultra-high-potency topical steroids should not be used continuously for longer than three weeks. Low- to high-potency topical steroids should not be used continuously for longer than three months to avoid side effects.
Combinations of topical steroids and antifungal agents generally should be avoided to reduce the risk of tinea infections. For information about the SORT evidence rating system, go to https: An accurate diagnosis is essential when selecting a steroid.
A skin scraping and potassium hydroxide test can clarify whether a steroid or an antifungal is an appropriate choice, because steroids can exacerbate a fungal infection. Topical corticosteroids are effective for conditions that are characterized by hyperproliferation, inflammation, and immunologic involvement. They can also provide symptomatic relief for burning and pruritic lesions.
Many skin conditions are treated with topical steroids Table 1 , but evidence of effectiveness has been established only for a small number of conditions. For example, high- or ultra-high-potency topical steroids, alone or in combination with other topical treatments, are the mainstay of therapy for psoriasis. Medium- to high-potency topical corticosteroids are effective for atopic dermatitis and eczema in adults and children, 9 , 10 as well as for phimosis 11 , 12 i.
Topical corticosteroids may be effective for other conditions, but the data to support their use are from small, low-level, or uncorroborated studies. Melasma, 15 chronic idiopathic urticaria, 16 infantile acropustulosis, 17 prepubertal labial adhesions, 18 and transdermal testosterone-patch—induced skin irritation 19 fall into this category. Steroids may differ in potency based on the vehicle in which they are formulated. Some vehicles should be used only on certain parts of the body.
Ointments provide more lubrication and occlusion than other preparations, and are the most useful for treating dry or thick, hyperkeratotic lesions. Their occlusive nature also improves steroid absorption.
Ointments should not be used on hairy areas, and may cause maceration and folliculitis if used on intertriginous areas e. Their greasy nature may result in poor patient satisfaction and compliance. Creams are mixes of water suspended in oil. They have good lubricating qualities, and their ability to vanish into the skin makes them cosmetically appealing. Creams are generally less potent than ointments of the same medication, and they often contain preservatives, which can cause irritation, stinging, and allergic reaction.
Acute exudative inflammation responds well to creams because of their drying effects. Creams are also useful in intertriginous areas where ointments may not be used.
However, creams do not provide the occlusive effects that ointments provide. Lotions and gels are the least greasy and occlusive of all topical steroid vehicles. Lotions contain alcohol, which has a drying effect on an oozing lesion.
Lotions are useful for hairy areas because they penetrate easily and leave little residue. Gels have a jelly-like consistency and are beneficial for exudative inflammation, such as poison ivy. Gels dry quickly and can be applied on the scalp or other hairy areas and do not cause matting.
Foams, mousses, and shampoos are also effective vehicles for delivering steroids to the scalp. They are easily applied and spread readily, particularly in hairy areas. Foams are usually more expensive. Because hydration generally promotes steroid penetration, applying a topical steroid after a shower or bath improves effectiveness.
Simple plastic dressings e. Irritation, folliculitis, and infection can develop rapidly from occlusive dressings, and patients should be counseled to monitor the treatment site closely.
Flurandrenolide Cordran 4 mcg per m 2 impregnated dressing is formulated to provide occlusion. It is beneficial for treating limited areas of inflammation in otherwise difficult-to-treat locations, such as fingertips. This is a useful but imperfect method for predicting the clinical effectiveness of steroids. There are seven groups of topical steroid potency, ranging from ultra high potency group I to low potency group VII.
Table 2 provides a list of topical steroids and available preparations listed by group, formulation, and generic availability. This should be considered when choosing steroid agents. Physicians should also be aware that some generic formulations have been shown to be less or more potent than their brand-name equivalent.
Information from reference Low-potency steroids are the safest agents for long-term use, on large surface areas, on the face or areas of the body with thinner skin, and on children.
More potent agents are beneficial for severe diseases and for areas of the body where the skin is thicker, such as the palms and bottoms of the feet. High- and ultra-high-potency steroids should not be used on the face, groin, axilla, or under occlusion, except in rare situations and for short durations.
Once-or twice-daily application is recommended for most preparations. Chronic application of topical steroids can induce tolerance and tachyphylaxis. Ultra-high-potency steroids should not be used for more than three weeks continuously. This intermittent schedule can be repeated chronically or until the condition resolves. Side effects are rare when low- to high-potency steroids are used for three months or less, except in intertriginous areas, on the face and neck, and under occlusion.
The amount of steroid the patient should apply to a particular area can be determined by using the fingertip unit method. Table 3 describes the number of fingertip units needed to cover specific areas of the body. The amount dispensed and applied should be considered carefully because too little steroid can lead to a poor response, and too much can increase side effects.
Prolonged use of topical corticosteroids may cause side effects Table 4 To reduce the risk, the least potent steroid should be used for the shortest time, while still maintaining effectiveness. The most common side effect of topical corticosteroid use is skin atrophy.
All topical steroids can induce atrophy, but higher potency steroids, occlusion, thinner skin, and older patient age increase the risk. The face, the backs of the hands, and intertriginous areas are particularly susceptible.
Resolution often occurs after discontinuing use of these agents, but it may take months. Concurrent use of topical tretinoin Retin-A 0. Topical steroids can also induce rosacea, which may include the eruption of erythema, papules, and pustules. Steroid-induced rosacea occurs when a facial rash is treated with low-potency topical steroids that produce resolution of the lesions. If the symptoms recur and steroid potency is gradually increased, the rosacea may become refractory to further treatment, making it necessary to discontinue the steroid.
This may then induce a severe rebound erythema and pustule outbreak, which may be treated with a day course of tetracycline mg four times daily or erythromycin mg four times daily. For severe rebound symptoms, the slow tapering of low-potency topical steroids and use of cool, wet compresses on the affected area may also help. The normal presentation of superficial infections can be altered when topical corticosteroids are inappropriately used to treat bacterial or fungal infections.
Steroids interfere with the natural course of inflammation, potentially allowing infections to spread more rapidly. The application of high-potency steroids can induce a deep-tissue tinea infection known as a Majocchi granuloma. Aggravation of cutaneous infection. Masked infection tinea incognito. Reactivation of Kaposi sarcoma.
Aseptic necrosis of the femoral head. Adverse effects of topical glucocorticosteroids. J Am Acad Dermatol. This tinea folliculitis requires oral antifungal therapy. Combinations of antifungal agents and corticosteroids should be avoided to reduce the risk of severe, persistent, or recurrent tinea infections.
Topical applications of corticosteroids can also result in hypopigmentation. This is more apparent with darker skin tones, but can happen in all skin types. Repigmentation often occurs after discontinuing steroid use. Steroids can induce a contact dermatitis in a minority of patients, but many cases result from the presence of preservatives, lanolin, or other components of the vehicle.
Topically applied high- and ultra-high-potency corticosteroids can be absorbed well enough to cause systemic side effects. Hypothalamic-pituitary-adrenal suppression, glaucoma, septic necrosis of the femoral head, hyperglycemia, hypertension, and other systemic side effects have been reported. According to a postmarketing safety review, the most frequently reported side effects were local irritation 66 percent , skin discoloration 15 percent , and striae or skin atrophy 15 percent.
Topical steroids can induce birth defects in animals when used in large amounts, under occlusion, or for long duration. Food and Drug Administration as pregnancy category C. It is unclear whether topical steroids are excreted in breast milk; as a precaution, application of topical steroids to the breasts should be done immediately following nursing to allow as much time as possible before the next feeding. Children often require a shorter duration of treatment and a lower potency steroid.
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