Introduction:
Topical steroids are medications that reduce inflammation of the skin. Inflammation is a sign of the immune response characterized by redness, heat, swelling, and pain. A significant proportion of dermatological conditions are treated by physicians other than a dermatologist, and all of them prescribe topical corticosteroids for most of these conditions. But the clinical outcome will depend on making a correct diagnosis and prescribing the correct molecule in the most relevant vehicle for the accurate duration. This article aims to provide information regarding the rational and safe use of topical steroids to improve their effectiveness and prevent adverse effects, thereby decreasing unnecessary medical expenses.
What Are the Classifications of Topical Steroids?
The topical corticosteroids are classified on the basis of how much vasoconstriction they cause and on comparative clinical trials. There are seven classes of corticosteroids ranging from most potent (class I) to least potent (class VII). Class I topical steroids are about 600 to 10000 times stronger than class VIII topical steroids. Topical preparations which have similar active compounds but differ in their concentration or vehicle have variable potency and efficacy. Topical steroids are also classified based on strengths:
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Mild.
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Moderate.
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Potent.
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Very potent.
Dermatoses of the face and intertriginous areas (where two skin areas touch or rub together) are best treated with a low-potent preparation. While lesions on the palm and soles frequently require highly potent steroids.
What Are the Indications of Topical Steroids?
Establishing a clinical diagnosis is the most important thing before prescribing a topical steroid.
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Inflammatory skin conditions like atopic dermatitis in children, seborrheic dermatitis (itchy red patches on the scalp), intertriginous psoriasis (skin rashes in the skin folds), etc., are highly responsive to steroids, so they require only weak topical steroids.
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Psoriasis (an autoimmune disorder that causes scaly patches on the skin), atopic dermatitis (a condition causing inflamed, itchy and dry skin) in adults, and nummular eczema (coin-shaped rashes or sores on the skin) are moderately responsive to topical steroids, so they require medium-potent topical steroids.
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Lichen planus (irritation and swelling of the skin, nails, hair, and mucous membrane), lichen simplex chronicus (thick skin markings caused by itching and excessive scratching and rubbing), and palmoplantar psoriasis (fluid-filled blisters on the hands and feet) need highly potent steroids.
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Skin infection, acne, perioral dermatitis (skin inflammation around the mouth), and rosacea (redness and pus-filled bumps on the face) are some contraindications to using steroids.
What Are the Formulations of Topical Steroids?
The potency of steroids may vary depending on the vehicle in which it is formulated.
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Ointment - Improve drug penetration as they occlude skin and increase hydration. Most useful in treating dry, hyperkeratotic, or thick lesions. It should not be used in hairy areas (it can cause folliculitis) or intertriginous areas. Its greasy nature and difficulty in spreading may lead to poor adherence.
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Cream - It is a combination of emulsifying agents and non-mixable liquids. They are not so much greasy and easy to spread, and washable. Less potent than ointment of the same medication. They are preferred for acute exudative inflammatory lesions because of their drying effect. They can also be used in intertriginous areas.
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Lotion and Gel - They are the least greasy and occlusive of all topical steroids. Lotions contain alcohol and have a drying effect on exudative lesions. They can also be used in hairy areas because they penetrate easily and leave less residue. Gels have a jelly-like consistency and dry quickly, so they are beneficial for oozing lesions and hairy areas like the scalp and do not cause matting.
How to Apply Topical Steroids?
Follow the instructions given by the doctor. If not instructed, follow the directions on the patient information leaflet with the medicine, giving details of how to apply and how often to apply. The medicine should only be applied to the skin’s affected area. Gently apply a thin layer onto the skin in the direction of the hair growth. Since hydration generally promotes steroid penetration, applying topical steroids after a shower or wetting the area improves effectiveness. Occlusion increases penetration. A simple plastic dressing increases the penetration by several-fold, compared to dry skin. The occlusive dressing should not be used on the face or intertriginous area. Folliculitis (infection of hair follicles) and irritation are common side effects of occlusion, so patients should be counseled and closely monitored.
What Is the Frequency and Dosage of Topical Steroids?
Once or twice daily application is recommended for most preparation. Treatment should not be longer than two weeks on the face and three to four weeks on the rest of the body. The long-term application can cause tolerance and tachyphylaxis (decrease in responsiveness to a drug). And also side effects like atrophy (loss of muscle tissue), telangiectasia (a condition in which widened blood vessels cause thread-like patterns on the skin), etc. Ultra-potent steroids should not be used continuously for more than three weeks. If needed for a more extended period, taper gradually and use intermittently. The amount of steroid to apply is measured by finger-tip units (FTU). One hand size of skin requires 0.5 FTU or 0.25 mg steroid.
What Are the Side Effects of Topical Steriods?
The most common side effect is a stinging or burning sensation when it is applied. Nevertheless, it improves as the skin gets used to the treatment. The less common side effects include:
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Spreading or worsening of the skin infection.
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Inflammation of hair follicles.
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Stretch marks.
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Changes in skin color.
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Excessive hair growth in the areas being treated.
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Thinning of the skin, making the affected skin more vulnerable.
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Acne.
If a person stops using topical corticosteroids after continuous use for a long time, he or she may experience withdrawal reactions which can be severe sometimes. Withdrawal reaction symptoms include:
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Redness or changes in skin color.
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Itching, burning, stinging, or peeling of the skin.
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Open sores.
Conclusion:
To conclude, topical steroids are safe and effective. Always establish a clinical diagnosis before prescribing and choose an appropriate topical steroid according to the affected area, clinical presentation, and predicted response to treatment. Monitor for clinical response and adverse effects. Consider stopping or changing the drug depending on the response. Consult a dermatologist if the disease does not respond to the treatment or the diagnosis is unclear.
