Rational Use of Topical Steroids

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 not only on making a correct diagnosis, but also prescribing the right molecule in the most appropriate vehicle for the exact duration.

The classification of topical corticosteroids was based on how much vasoconstriction they cause and on some comparative clinical trials. There are seven classes of corticosteroid ranging from most potent (class1) to least potent (class 7). Topical preparations which have similar active compound but differ in their concentration or vehicle have variable potency and efficacy. Let us consider the factors affecting the effectiveness of topical corticosteroid treatment.

Indications:

Establishing a clinical diagnosis is the most important thing before prescribing a topical steroid.

• Inflammatory skin conditions like atopic dermatitis in children, seborrheic dermatitis, intertriginous psoriasis, etc., are highly responsive to steroid, so they require only weak topical steroids.

• Psoriasis, atopic dermatitis in adults, nummular eczema are moderately responsive to topical steroids, so they require medium potent topical steroids.

• Chronic hyperkeratotic, lichenified and indurated lesions such as lichen planus, lichen simplex chronicus, and palmoplantar psoriasis need high potent steroids.

• Skin infection, acne, perioral dermatitis, and rosacea are some contraindications to use steroids.

Drug Formulation:

The potency of steroid may vary depending on the vehicle in which it is formulated.

• Ointment - improve drug penetration as they occlude skin and increase hydration. Most useful in treating dry, hyperkeratotic, or thick lesions. Should not be used in hairy areas (can cause folliculitis) or intertriginous areas. Its greasy nature and difficulty in spreading may lead to poor adherence.

• Cream - it is a combination of one or more non-mixable liquid and an emulsifying agent. They are less 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 its drying effect. They can also be used in intertriginous areas.

• Lotions 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 on hairy areas like scalp and do not cause matting.

Location:

Dermatoses of the face and intertriginous areas are best treated with a low potent preparation. While lesions on palm and soles frequently require high potent steroids.

Method of Application:

Because hydration generally promotes steroid penetration, applying topical steroid after a shower or wetting the area improves effectiveness. Occlusion increase penetration. A simple plastic dressing increases the penetration by several-fold, as compared to dry skin. Occlusive dressing should not be applied to the face or intertriginous area. Folliculitis and irritation are common side effects of occlusion, so patients should be counseled and closely monitored.

Frequency and Dosage:

Once or twice daily application is recommended for most preparation. Treatment should not be longer than two weeks on the face and 3 to 4 weeks on the rest of the body. The longterm application can cause tolerance and tachyphylaxis. And also side effects like atrophy, telangiectasia, etc. Ultra potent steroid should not be used more than three weeks continuously. 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.

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 response. Refer to a dermatologist if the disease does not respond to your treatment or when the diagnosis is unclear.