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Given the wide variety of topical steroids, this author reviews the potency and absorption of these agents, the pros and cons of different formulations, and potential side effects.
Take this test online and receive your certificate instantly. (Priority Code AGU481)
Continuing Education Exam #164 — June 2008 | - I am pleased to introduce the latest article, “A Guide To Topical Steroid Use For Dermatological Conditions,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of complimentary CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.
There are a variety of factors that physicians must consider when it comes to choosing the most appropriate and efficacious topical steroid for a given dermatological condition. With this in mind, M. Joel Morse, DPM, provides a comprehensive guide to steroid agents and discusses potency, absorption and the different formulations for these agents. He also reviews potential side effects and offers key tips on prescribing these modalities.
At the end of this article, you’ll find a nine-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) after the publication date. I hope this CE series contributes to your clinical skills.
Sincerely,
Jeff A. Hall
Executive Editor
Podiatry Today
INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 66 and successfully answering the questions on pg. 74. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Morse has disclosed that he has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of his presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists
RELEASE DATE: June 2008
EXPIRATION DATE: June 30, 2009
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• discuss the mechanisms of action for topical steroids;
• review the classes and potency levels of topical steroids as per the National Psoriasis Foundation;
• review the types of formulations for steroids and their advantages and disadvantages;
• prescribe appropriate topical corticosteroids and instruct patients in their application;
• cite potential cutaneous and systemic side effects that may occur with topical corticosteroid use; and
• list psoriatic disorders and inflammatory skin disorders that may benefit from treatment with topical steroids.
Sponsored by the North American Center for Continuing Medical Education.
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Topical corticosteroids have been in extensive use for over 50 years and physicians commonly prescribe these agents for dermatological problems. There are four separate groups of steroids: mineralocorticoids (aldosterone), glucocorticoids (cortisol), androgens (testosterone) and estrogens (estrogen and progesterone). They are grouped by the receptors to which they bind. Synthetic steroids interact with the steroid receptors because of a similarity of shape and exert the desired effect. Glucocorticoids have been synthetically manufactured for use on the skin.
Since topical steroids first became commercially available in 1952, physicians have utilized many preparations with different potencies and structures to treat different skin lesions. In 1990, the FDA agreed that topicals of strengths up to 1% were safe for over-the-counter sales.1 Over the years, we have seen the emergence of newer steroid preparations that have increased usage for a large variety of skin conditions.
Understanding How Topical Steroids Work
Topical steroids work by reducing inflammation in the skin via several different mechanisms of action.
These agents alter chemicals that cause inflammation. The steroid molecule is transported to the cell nucleus where it interacts with DNA. The molecules exert their potent anti-inflammatory effects by inhibiting the release of phospholipase A2, an enzyme responsible for the formation of prostaglandins, leukotrienes and other derivatives of the arachidonic acid pathway. This interaction causes the cell to turn off the production of arachidonic acid. Without arachidonic acid, many chemicals that cause inflammation in the skin and the rest of the body are not produced.
|  | | With allergic dermatitis (as shown above), a substance serves as an allergen and elicits a cell-mediated or delayed hypersensitivity reaction. |
Topical steroids also inhibit histamine release and reduce the sensitivity of the vascular smooth muscle to histamine, and increase peripheral resistance.6 Acetate types of steroids generally have the greatest anti-inflammatory property. After these agents, alcohol-based steroids and phosphate types of steroids have the next greatest amount of anti-inflammatory activity.
Topical steroids also have the immediate effect of constricting capillaries. A section of skin that has dilated capillaries will be red, warm and swollen. Therefore, causing the capillaries to constrict decreases redness, warmth and swelling. The vasoconstrictive effects of the corticosteroid facilitate maintenance of the drug in place for extended periods of time.7 The fluorinated steroids are thought to be the most vasoconstrictive steroids.
Topical steroids also change the function of immune system cells. White blood cells do not recognize foreign cells as well and have a decreased capacity to fight off these foreign cells.
There are anti-proliferative effects as well. Steroids have a skin thinning effect, which results in the loss of ground substance secondary to decreased binding of tissue fluid to the hyaluronic acid. However, this skin thinning effect is a double-edged sword. While it allows the drug to penetrate more easily to exert its effect, the skin thinning decreases the protective nature of the skin.
|  | | Here one can see atopic dermatitis, a highly pruritic rash. One should watch for secondary bacterial infections. |
What About The Absorption Of Topical Corticosteroids?
The effectiveness of topical corticosteroids depends on the pharmacological structure of the drug, its potency, the physiochemical characteristics of the vehicle, the state of the skin surface, age, duration of application and the degree of penetration into the skin.
Steroids are absorbed at different rates from different parts of the body based on the skin thickness and blood flow. A steroid that works on the face may not work on the sole. A potent steroid may cause side effects on the face. In one study that looked at absorption rates based on skin thickness, researchers offered the following findings:
• the forearm absorbs 1 percent;
• the armpit absorbs 4 percent;
• the face absorbs 7 percent;
• the eyelids and genitals absorb 30 percent;
• the palm absorbs 0.1 percent; and
• the sole absorbs 0.05 percent.8
Given these numbers, one can understand why physicians might use more high potent steroids on the sole of an average adult but would not utilize these agents on the dorsum of the foot (unless it were lichenified). The dorsum of the foot absorbs 150 times as much medication as the sole of the foot.
Pertinent Insights On The Variety Of Formulations
The common topical formulations include creams, ointments, gels, solutions and foams. All topical steroids have common ingredients: the active drug, a vehicle (cream, ointment) and sometimes a preservative. The strength of the steroid is affected by the vehicle, concentration and potency. Certain skin types and body areas are better suited for one type of vehicle over another. Overall, the vehicle must allow adequate release of the active drug and be non-allergenic, non-irritating and cosmetically acceptable.
When choosing the type of topical preparation, physicians should weigh the following factors.
• Match the type of preparation with the type of lesions.
• Consider the effect of the vehicle.
• Match the type of preparation with the affected skin site.
• If allergy is a concern, use ointments or foams as these vehicles have no preservatives.
|  | | Ichthyosis vulgaris (as shown above) is an inherited disorder that presents early in life and is characterized by dry, fish-like skin. |
Ointments. Ointments are semi-solid preparations of hydrocarbon and are oil-based vehicles. Strong emollients make ointments useful in dry skin conditions. The occlusive effect of ointments enhances the penetration of active drugs and improves efficacy, especially in thickened, lichenified skin. It allows the skin to maintain moisture and provides a protective film on the skin.
Bear in mind that ointments retain sweat. Therefore, these vehicles are not suitable for wet, weeping dermatitis, on hairy areas or in hot weather conditions. The ointments do not contain water and also do not contain a preservative.
Creams. A cream is an emulsion of water and oil with less oil than ointments and more alcohol. Cream contains emulsifiers and preservatives, which may cause allergies. They are less greasy and therefore more cosmetically appealing. The increased alcohol content may be irritating to skin with open cuts.
Solutions. These vehicles contain more water and alcohol, and have less oil than creams. They are more irritating to skin than creams. One may use solutions to cover a large skin area.
Gels. Gels contain more alcohol and less oil than solutions, and are more drying than cellulose ethers or a water/alcohol mixture. They liquefy on contact with the skin and are drying. Gels are useful in hairy areas and between the toes.
Foams. These contain ethanol, water, cetyl and stearyl alcohol and polysorbate 60. Foam does not have a preservative. These modalities are not as messy as other formulations and also have a better cosmetic appearance.
Foam vehicles have the advantage of minimal residue and increased ease of application. Foams reportedly have an increased ability to deliver a greater amount of active drugs at an increased rate.
Strength And Potency Of Topical Steroids: What You Should Know
Hydrocortisone is the most common topical steroid. It is a natural chemical that the body makes and is one of the weakest topical steroids. Cortisone and hydrocortisone preparations have minimal anti-inflammatory reaction and very few side effects. Alternatively, fluorinated groups have high anti-inflammatory reactions and many side effects such as striae, telangiectasia, skin atrophy and even systemic side effects.
In the United States, the potency of steroids is organized into seven rankings with 1 being the strongest and 7 the weakest. Since we primarily treat the foot and ankle, we generally do not have to worry about major side effects. The National Psoriasis Foundation has the most current listing of the topical steroids (see “A Guide To The Potency Of Topical Steroids” below).9
It is very important to note that the percentage of ingredient in the medication does not necessarily correlate with the strength of the steroid. For example, halcinonide 0.1% is not a strong as clobetasol propionate 0.05%, yet it has a higher percentage of the drug.
When it comes to very potent formulations, one should limit the dosing to short periods of time (14 to 20 days) or intermittently to reduce adverse events. Potent or very potent formulations are usually required on soles, and for lichenified and hypertrophic dermatoses.
Scratching can cause increased thickness of the skin. Brief use of a more potent steroid achieves faster control of eczema and may result in less steroid use in comparison with long use of inadequately potent preparations. Occlusion is often necessary on soles to enhance penetration of the active molecule through the thicker stratum corneum. Do not use corticosteroids on ulcerated or atrophic skin such as the thin skin of an older person. Flurandrenolide tape 0.05% is great for localized lesions that patients tend to want to scratch.9
A Pertinent Overview Of Skin Structure And Adrenal Glands | - In order to select the appropriate agent, physicians must have a strong understanding of how topical corticosteroids affect skin structure and the adrenal gland.
The epidermis (top layer of skin) is stratified squamous epithelium, which is composed of keratinocytes. The stratum corneum is the outermost layer of non-living keratinocytes. This layer offers the major resistance to drug penetration and permeation. The transport of the topical corticosteroid across the stratum corneum is mostly via passive diffusion and is very dependent on the vehicle. There are lipids on the skin surface and the prevailing thinking is that the drug interacts with this substance, and it changes in composition in order to penetrate.
Drugs diffuse across the skin by transappendageal and epidermal routes.2 In regard to the transappendageal route, the drug penetrates at sites of discontinuities in the skin barrier. These sites include the hair follicles, sebaceous glands and sweat glands. The epidermal route is directly through the stratum corneum by way of hydrophilic and lipophilic routes.3
Physicians must pair topical steroids with a vehicle in order for them to gain entry into the skin and pass from one layer to the next. Haung notes that penetration is the entry of a vehicle and active agent into the skin layer; permeation is the penetration of the drug to the other layers; and absorption is when the topically applied drug enters the systemic circulation.4 When it comes to treating skin conditions, we wish to minimize the systemic absorption and keep the drug in the area of concern.
Bear in mind that children and infants are more susceptible to topical steroids and their systemic effects because they have a larger skin surface area in relation to body weight.
How The Adrenal Glands Come Into Play
In a normal individual, the adrenal glands normally secrete about 25 mg of cortisol (hydrocortisone) and 5 mg of corticosterone per day. Only about 5 percent of these steroids are biologically active with the remainder being bound to plasma protein. Since a small amount of natural steroid dramatically modulates a myriad of metabolic activities, one should be conservative in his or her use of synthetic steroids in clinical practice.
Corticosteroids are a class of steroid hormones that the adrenal cortex produces. This process starts with cholesterol, which then goes through a series of reactions in the adrenal gland to produce a variety of steroid hormones. One end product of this pathway is cortisol, which is then released from the adrenal gland by ACTH signaling from the anterior pituitary, which is stimulated by corticotropin-releasing hormone from the hypothalamus in the brain.5
Corticosteroids are involved in a wide range of physiologic systems such as stress response, immune response and regulation of inflammation, carbohydrate metabolism, protein catabolism, blood electrolyte levels and behavior. Glucocorticoids such as cortisol control carbohydrate, fat and protein metabolism, and are anti-inflammatory by preventing phospholipid release, decreasing eosinophil action and a number of other mechanisms.5
Cortisone is less important than a similar steroid cortisol. Cortisol is responsible for 95 percent of the effects of the glucocorticosteroids whereas cortisone is responsible for 4 or 5 percent. In regard to synthetic glucocorticoids, physicians utilize these agents in the treatment of joint pain or inflammation (arthritis), temporal arteritis, dermatitis, allergic reactions, asthma, hepatitis, systemic lupus erythematosus, inflammatory bowel disease and sarcoidosis.
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How To Apply And Dose Topical Steroids
Patients usually apply the medication to moist skin after bathing or soaking the area in water. They rub the medication thoroughly into the skin surface.
Sometimes the occlusion method is necessary. Patients do this by covering the area with cellophane tape after applying the medication or use special tapes containing the active corticosteroid (flurandrenolide tape). First, patients should wash the area to be treated, rub the ointment into the area and then occlude it.
Research has found that the occlusion increases the potency of the corticosteroid by about 100 times that of the free application on the skin surface. This is mainly related to the hydration of the occluded area, which causes an increased penetration of the preparation. Patients should keep the entire applied amount in contact with the skin surface for an extended amount of time.
|  | | Here one can see lichen chronicus simplex. This is a circumscribed neurodermatitis characterized by a pruritic, lichenified plaque due to scratching and rubbing. |
The occlusion method is mainly for solitary or few lesions. It is not appropriate for wide areas so as to avoid unwanted local and systemic side effects.
While the use of oral medications is rather straightforward in that the directions include the dose and intervals of the medication, there has always been less specificity when it comes to topical steroid dosages. Long and Finley have described a convenient way to measure how much medication to prescribe to a patient with a skin disease.10
A fingertip unit (FTU) is the amount patients apply from the distal skin crease to the tip of the index finger. In one study, 30 adult patients treated various anatomical regions using FTUs of ointment. In regard to the number of FTUs required, they used 3.3 FTUs for the arm and forearm, 1.2 FTUs for the hand, 5.8 FTUs for the leg and thigh, and 1.8 FTUs for the foot. The use of the FTU in dermatological prescribing provides a readily understandable measure for both the patient and the doctor.10
In my clinical experience, I have found that the amount of cream used varies with the body part. When it comes to treating one hand, apply one FTU. On one arm, apply three FTUs. On one foot, apply two fingertip units. On one leg, apply six fingertip units. Of course, patients only apply the steroid on the involved skin so it may be less than a FTU.
Also be aware that the dose of cream for a FTU varies with age. In an adult male, one FTU provides 0.5 g whereas the FTU is 0.4 g for females. For children age 4 and older, one would use approximately one-third of the adult amount. For infants, ranging in age from six months to a year in age, use one-fourth of the adult amount.
A Guide To The Potency Of Topical Steroids | - When it comes to selecting a topical steroid to facilitate optimal treatment and minimize potential side effects, podiatrists may want to consider the following guide from the National Psoriasis Foundation. Here is a guide to the potency of topical steroid agents.
Class 1: Super Potent (up to 600 times stronger than hydrocortisone)
Diprolene ointment 0.05% (betamethasone dipropionate)
Olux E Foam 0.05% (clobetasol propionate)
Olux Foam 0.05% (clobetasol propionate)
Temovate cream/ointment/solution 0.05% (clobetasol propionate)
Ultravate cream/ointment 0.05% (halobetasol propionate)
Vanos cream 0.1% (fluocinonide)
Psorcon ointment 0.05% (diflorasone diacetate)
Psorcon E ointment 0.05% (diflorasone diacetate)
Class 2: Potent (50 to 100 times as potent as hydrocortisone)
Diprolene cream AF 0.05% (betamethasone dipropionate)
Elocon ointment 0.01% (mometasone furoate)
Florone ointment 0.05% (diflorasone diacetate)
Halog ointment/cream 0.1% (halcinonide)
Lidex cream/gel/ointment 0.05% (fluocinonide)
Psorcon cream 0.05% (diflorasone diacetate)
Topicort cream/ointment 0.25% (desoximetasone)
Topicort gel 0.05% (desoximetasone)
Class 3: Upper Mid Strength (2 to 25 times as potent as hydrocortisone)
Cutivate ointment 0.005% (fluticasone propionate)
Lidex-E cream 0.05% (fluocinonide)
Luxiq foam 0.12% (betamethasone valerate)
Topicort LP cream 0.05% (desoximetasone)
Class 4: Mid Strength
Cordran ointment 0.05% (flurandrenolide)
Elocon cream 0.1% (mometasone furoate)
Kenalog cream/spray 0.1% (triamcinolone acetonide)
Synalar ointment 0.03% (fluocinolone acetonide)
Westcort ointment 0.2% (hydrocortisone valerate)
Class 5: Low to Mid Strength
Cordran cream/lotion/tape 0.05% (flurandrenolide)
Cutivate cream/lotion 0.05% (fluticasone propionate)
DermAtop cream 0.1% (prednicarbate)
DesOwen lotion 0.05% (desonide)
Synalar cream 0.03/0.01% (fluocinolone acetonide)
Westcort cream 0.2% (hydrocortisone valerate)
Class 6: Mild
Aclovate cream/ointment 0.05% (alclometasone dipropionate)
Derma-Smoothe/FS Oil 0.01% (fluocinolone acetonide)
Desonate gel 0.05% (desonide)
Synalar cream/solution 0.01% (fluocinolone acetonide)
Verdeso foam 0.05% (desonide)
Class 7: Least Potent
Cortaid cream/spray/ointment 1% (hydrocortisone)
Hytone cream/lotion 1%/2.5% (hydrocortisone)
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What You Should Know About Systemic And Cutaneous Side Effects
A 2008 FDA advisory committee hearing noted that prescription topical corticosteroids may have more potential to cause adrenal suppression than many physicians realize.1 With the limited skin surface area of the foot, this is of less concern but the potential does exist.
The suppression can lead to debilitating and potentially fatal conditions such as Cushing’s syndrome. The biggest problems seemed to be with betamethasone propionate, which was approved in 2001 and is available as a cream, ointment or lotion.
Systemic absorption can cause hypothalamic-pituitary-adrenal (HPA) axis suppression. Conditions that enhance corticosteroid absorption include inflammation, use over a large surface area, prolonged use and the use of an occlusive dressing.
Side effects can also increase when using moderate, potent or very potent steroids too long, too often, too much, under occlusion, over an extensive area or in people who are too old or too young.
Currently, all the drugs in the class carry warnings that systemic absorption can cause HPA axis suppression, which can lead to Cushing’s syndrome, hyperglycemia and glucosuria. In regard to Cushing’s syndrome, if large amounts of steroid are absorbed through the skin, fluid retention, increased blood pressure, diabetes and other conditions may result.
Most of the serious problems follow prolonged or excessive use of the drugs, the use of a super-potent steroid, the use of multiple topical steroids or using them at the same time as oral or inhaled steroids. It is imperative that the physician knows what other medications the patient is currently using.
Systemic side effects include adrenal gland suppression. Topical steroids can suppress the production of natural steroids, which are essential for healthy living. Stopping the steroids suddenly may result in illness.
Topical steroids can cause cutaneous side effects. While these side effects do not usually occur on the feet due to the thicker skin, podiatrists should be aware of the potential for the following effects:
• skin thinning (atrophy) and stretch marks (striae);
• easy bruising and tearing of the skin;
• enlarged blood vessels (telangiectasia) and purpura;
• susceptibility to skin infections;
• disguised infection (e.g. tinea incognito);
• allergic symptoms such as irritation, redness, burning, stinging, peeling;
• masking of initial lesions;
• pigmentation abnormalities (lightening or darkening of the skin); and/or
• delayed wound healing.11
The risk of these side effects depends on the strength of the steroid, the length of application, the site treated and the nature of the skin problem. If the patient uses a potent steroid cream on the face, he or she may develop the side effects within a few weeks. Use of 1% hydrocortisone cream on the soles for 25 years will not harm patients at all.
In the aforementioned 2008 FDA hearing, researchers cited a study in which the use of betamethasone dipropionate (0.05%) to treat atopic dermatitis in patients 1 to 12 years of age caused adrenal suppression in 58 percent of the patients. In that same study, the use of betamethasone dipropionate ointment (0.05%) led to adrenal suppression in 53 percent of patients.
In another study, researchers found the use of clobetasol propionate led to adrenal suppression in 56 percent of adults who used the drug for
two weeks.
Key Points To Consider When Treating Children | - Children are at greater risk of side effects from topical steroid agents and are more vulnerable to growth retardation, delayed weight gain and intracranial hypertension.
For pediatric patients, one should limit the topical application of a steroid to the least amount and for the shortest period to cause the therapeutic response. Mometasone furoate and fluticasone propionate are the only topical steroids approved for use for children.
Even 0.5% and 1% hydrocortisone formulations that are available without prescription are not approved for use in children. Fluticasone propionate is the only topical steroid approved for children as young as 3 months old.
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What Are The Indications For Topical Corticosteroids?
Topical steroids are indicated for many skin conditions and diseases. These include allergic skin diseases, pruritic skin lesions, papulosquamous hyperplastic lesions, collagen diseases, vesiculobullous diseases and infiltrating diseases. The more prevalent conditions are eczematous conditions, psoriasis and related disorders, immune and autoimmune disorders, and skin disorders secondary to medications.
Eczematous conditions include a wide variety of cutaneous inflammatory conditions that are characterized by erythema, papules, vesicles, pustules, crusts and scales. The terms dermatitis and eczema are often used synonymously.
**PT0654891.jpg**
Eczema describes all kinds of superficial skin inflammation characterized by redness, blistering, oozing, edema, scaling, crusting, brownish lesions, thickened skin and itching skin conditions. These conditions may cause skin disfigurement, rashes and uneven pigmentation.
Atopic dermatitis. This is a highly pruritic rash. Watch for secondary bacterial infections.
Irritant contact dermatitis. With this condition, substances such as detergents, bleach, alcohol or lye may cause irritation to the patient’s epidermis.
Allergic contact dermatitis. With this dermatitis, a substance serves as an allergen and elicits a cell-mediated or delayed hypersensitivity reaction. This is caused by neosporin, sunscreens, nickel, rubber, formaldehyde and plastics.
In both types of dermatitis, erythema develops into papules and vesicles, and eventually erosions, crusting and scaling.
Lichen chronicus simplex. This is a circumscribed neurodermatitis characterized by a pruritic, lichenified plaque due to scratching and rubbing. This is most common on the lateral lower leg and ankle areas. One may also see this in the toe web space due to itching or rubbing a tinea infection.
Nummular eczema. This is a pruritic inflammatory disorder of uncertain etiology.
Dyshidrotic eczema. Also known as pompholyx, this condition is a vesicular recurring rash that occurs in the hand and foot. The etiology is unknown. Some patients have a history of atopy and stress.
What About Psoriatic Disorders And Inflammatory Skin Disorders?
Psoriasis vulgaris. With this condition, patients experience thick, scaly pruritic patches or plaques due to epidermal hyperplasia secondary to an accelerated rate of growth.
Ichthysosis vulgaris. This inherited disorder presents early in life and is characterized by dry, fish-like skin.
Granuloma annulare. This inflammatory skin disorder affects the dorsum of the feet and hands.
Lichen planus. This is a benign inflammatory skin eruption. Podiatrists may see flat topped pruritic eruptions on the ankles that are characterized by the 4 Ps (purple, pruritus, planar, polyangular).
A Brief Overview Of Immune And Autoimmune Disorders
Urticaria. Urticaria is an immune hypersensitivity disorder that appears as erythematous raised circles or wheals that may be confluent. This condition can be caused by many things including: medications, foods, systemic conditions, inhalants, chemicals, infections, stings, heat, cold, etc.
Erythema multiforme. This immune complex disease, triggered by antigens or drugs, begins as a central papule with concentric rings (target lesion).
Bullous pemphigoid. This chronic autoimmune disease causes bullae in older people.
Recognizing The Signs Of Skin Disorders Caused By Medications
Skin disorders secondary to medications usually present with a symmetric distribution of a pruritic red rash with associated issues such as urticaria, arthralgia, facial edema, purpura, fever and adenopathy. This begins on the trunk but may involve the palms and soles.
Fixed drug eruption. Such an eruption is a hypersensitivity reaction to medications that cause an asymmetric rash. It is only caused by ingested or parental medications and foods, and not caused by topical medications.
Exanthematous drug eruption. This is the most common drug reaction rash due to oral, parental and topical medications.
Pertinent Tips For Prescribing Topical Steroids | - • Occlusion such as plastic wrap increases the amount of steroid absorbed into the skin. Many topical agents are too strong in potency to cover. While the occlusion with these agents can increase the effectiveness, it can also increase the side effects.
• Pulse dosing can minimize the risk of side effects.
• In children, one should use mild to mid-strength steroids.
• Exercise caution in treating nursing mothers, who can absorb topical steroids through the skin and into breast milk.
• One should apply steroids to lesions two to three times a day with lower potency agents or once or twice a day with higher potency agents. When the rash is under control, switch to lower potency for maintenance.
• If the condition is severe, one may use oral steroids such as prednisone for seven to 10 days. For adults, it is 70 to 80 mg daily to start and tapering by 5 to 10 mg every two to three days. For children, it is 1 mg/kg daily and tapering 5 to 10 mg every two to three days.
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In Conclusion
Topical corticosteroids are among the most commonly prescribed drugs in the management of dermatological problems. With technological advances in recent years, we have seen the emergence of newer topical steroids that are manufactured in a wide range of sophisticated vehicles and marketed under a variety of brand names.12
Podiatrists will occasionally have a dilemma in choosing the correct steroid to achieve the desired benefit without producing undue side effects from the long list of commercially available topical corticosteroid preparations. However, with a strong understanding and application of some of the aforementioned principles, podiatrists should be able to select to select the most efficacious agent with the least risk of side effects.
When it comes to common presentations of dermatological conditions in the lower extremity, here are my recommendations.
• Severe scaling, crusting of plantar foot: Super potent ointment 0.05% (betamethasone diproprionate, clobetasol propionate)
• Moderate scaling of plantar foot: Potent ointment gel 0.05% (fluocinonide, desoximetasone, diflorasone diacetate)
• Moderate scaling of dorsum foot: Upper mid-strength (betamethasone valerate 0.12%, fluocinonide 0.05%, desoximetasone 0.05%)
• Children with atopic dermatitis flare: fluticasone propionate 0.05%, mometasone furoate cream 0.1%
• Local single pruritic scale: flurandrenolide tape 0.05%
Also remember that low mid-strength, mild and least potent topical steroids are rarely needed for foot dermatoses.
Use the steroids once or twice a day for one to three weeks and re-evaluate. If there is a positive response, maintain treatment with a weaker steroid or moisturize to keep skin free of an abnormal skin condition.
Dr. Morse is the President of the American Society of Podiatric Dermatology. He is a Fellow of the American College of Foot and Ankle Surgery, and the American College of Foot Ankle Orthopedics and Medicine. Dr. Morse is board certified in foot surgery.
References
1. Ault A. Adrenal Suppression from Topical Steroids Surprisingly High in http://www.medpagetoday.com/Dermatology/Steroids/tb/777
2. Williams AC, Barry BW. Skin absorption enhancers. Crit Rev Ther Drug Carrier Syst 9:305-53, 1992.
3. Schaefer H, Redelmeier TE, Nohynek GJ Pharmacokinectics and topical applications of drugs. In: Freeberg IM, Eisen AZ, Wolff K, Austen K, Goldsmith LA, SI, editors. Fitzpatrick’s dermatology in general medicine. Vol. 2 6th ed. New York. McGraw-Hill; 2300 – 2321, 2003.
4. Huang X, Tanojo H, Lenn J, Deng H, Krochmal L. A Novel Approach For Delivery of Topical Steroids. J Am Acad. Dermatology. 53(1) s26 – s37, 2005.
5. Stein JH. Internal medicine. 4th Edition. Mosby, St Louis. 1350 -1361, 1994.
6. Rai R, Uppal M, Sharma NK, Srinivas CR, Mathew A. Half an hour versus three hour contact of topical steroid (clobetasol propionate. Indian J Dermatol Venerol Leprol 70: 214 – 216, 2004.
7. http://www.netdoctor.co.uk/skin_hair
/eczema_corticosteroids_003762.htm
8. http://dermnetnz.org/treatments/topical-steroids.html
9. http://www.psoriasis.org/treatment/psoriasis/steroids/potency.php
10. Long CC, Finlay AJ. The fingertip unit—a new practical measure. Clinical and Experimental Dermatology 16(6):444–447, 1991.
11. http://www.eczemaguide.com/eczema_
treatments/topical/topical_corticosteroids.html
12. Reddy BSN, Shantharaman R. Comparative Evaluation of Topical Corticosteroid creams. Venereol Lrprol 58;23-4, 1992.
For further reading, see “Steroid Injections: Are They Overutilized In Athletes” in the September 2007 issue of Podiatry Today, “When Injection Therapy Can Help Relieve Painful Lesions” in the June 2002 issue or “A Closer Look At Eczematous Dermatitis In Athletes” in the February 2005 issue.
Also check out the archives at www.podiatrytoday.com.
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