Topical Steroids

TOPICAL STEROIDS

Glucocorticoids are used topically for a large variety of dermatological conditions. They bene fit by virtue of their anti-inflammatory, immunosuppressive, vasoconstrictor and antiproliferative (for scaling lesions) actions. The intensity of action depends on the extent of absorption to the deeper layers, thus lipophilicity of the compound determines potency to a great extent. Fluorinated compounds and lipid soluble esters, e.g. hydrocortisone butyrate are potent. The available preparations may be roughly graded as:

General Guidelines For The Use Of Topical Steroids

(i) Penetration of the steroid at different sites differs markedly—high at axilla, groin, face, scalp and scrotum; medium at limbs and trunk: low at palm, sole, elbow and knee. Areas of high penetration easily develop adverse effects—potent preparations should be avoided. Areas of low penetration do not generally respond to milder agents.

(ii) Absorption into the skin also depends on the nature of lesion—high in atopic and exfoliative dermatitis, low in hyperkeratinized and plaque forming lesions. Milder drugs should be used of acute lesions, stronger ones reserved for chronic lesions.

(iii) Choice of vehicle is important. Lotions and creams (to some extent) are better for exudative lesions—they allow evaporation, have a cooling, drying and antipruritic effect. Sprays and gels are appropriate for hairy regions. Ointments form an occlusive film and are good for chronic, scaly conditions.

(iv)  Occlusive  dressing  markedly  enhances absorption of the steroid (as much as 10 fold), retains moisture and results in maceration of the horny layer. Chronic, hypertrophied lesions may be occluded intermittently (12 hours at a time). Continuous occlusion promotes bacterial and fungal growth.

(v) Absorption is greater in infants and young children—milder agents should be used. Routine use of potent steroids is not justified. Very potent preparations should be restricted to severe inflammatory conditions, unresponsive eczema, psoriasis, etc., and that too only for short periods till the lesion resolves. The mildest preparation that will control the lesion should be used.

(vi) Use of potent preparations should be short term or intermittent to prevent adverse effects and tachyphylaxis. Sudden discontinuation should be avoided. Upon improvement a less potent preparation may be substituted or the steroid may be alternated with an emollient till the lesion resolves.

(vii) More than 2 applications a day do not afford additional benefit. Generally twice daily application is satisfactory.

A combination of steroid with an antimicrobial may be used for—impetigo, furunculosis, secondary infected dermatoses, napkin rash, otitis externa, intertriginous eruptions.

Local Adverse Effects Of Topical Steroids

Thinning of epidermis Dermal changes—atrophy Telangiectasia, Striae Easy bruising Hypopigmentation Delayed wound healing Fungal and bacterial infections

Related to the potency of preparation and duration of treatment; skin of face is more susceptible. Potent haloginated steroids not to be used on face.

Systemic Adverse Effects Of Topical Steroids

Adrenal pituitary suppression can occur if large amounts are applied repeatedly. Infants and children are particularly susceptible. Rarely, Cushing’s syndrome has been reported. With proper use, the systemic risks are minimal.

Popular Combinations Are:

Containing Neomycin (0.3–0.5%): BECLATEN, BETASONEN, COLSIPANN, DECADRON, KENACOMB, KENALOGS SKIN, TOPICASONE.

Containing Chinoform or Quiniodochlor (3–4%): BECLATE-C, BETASONE-C, BETNOVATE-C, CORTOQUINOL, FLUCORT-C

Containing Gentamicin (0.1%): GENTICYN-HC TOPICAL,  DERMOTYL-G,  LOBATE-G

Containing Chloramphenicol (1%): CORTISON-KEMICETINE

Containing Providone       iodine (1%): ECZO BETADINE

Containing Miconazole (2%): FLUCORTMZ, TENOVATE-M

Containing Clotrimazole (1%): CLOBEN