Topical steroidTopical corticosheroids TC have greatly contributed to the dermatologist's ability to effectively treat several difficult corticosteeoids. The available range of formulations and potency clen t3 cycle before after flexibility to treat all groups of patients, different phases of disease, and different anatomic sites. However, the rapid rise in incidence of improper use of these drugs by dermatologists, general physicians, and patients threatens to bring disrepute to the entire group of these amazing drugs. Responsibility to topical corticosteroids function primarily as proper knowledge regarding when, where, and how to use TC both to internists and patients rests primarily with the dermatologist. Benefits of rational and ethical use and the harm of overuse and misuse for nonmedical, specially topical corticosteroids function primarily as cosmetic purposes, should be clearly conveyed before penning a prescription involving TC.
Rational and Ethical Use of Topical Corticosteroids Based on Safety and Efficacy
Topical corticosteroids TC have greatly contributed to the dermatologist's ability to effectively treat several difficult dermatoses. The available range of formulations and potency gives flexibility to treat all groups of patients, different phases of disease, and different anatomic sites. However, the rapid rise in incidence of improper use of these drugs by dermatologists, general physicians, and patients threatens to bring disrepute to the entire group of these amazing drugs.
Responsibility to disseminate proper knowledge regarding when, where, and how to use TC both to internists and patients rests primarily with the dermatologist.
Benefits of rational and ethical use and the harm of overuse and misuse for nonmedical, specially for cosmetic purposes, should be clearly conveyed before penning a prescription involving TC.
Simultaneous efforts to use political, legal, and other institutions to prevent misuse of these drugs by rationing their availability only through proper prescriptions will greatly help the cause. This will hopefully bring down both the extremes of ever increasing cases of steroid-induced dermatoses on one hand and the irrational fears of using TC in well justified indications on the other.
The topical corticosteroids TC are among the most commonly prescribed medication in an out-patient dermatology setting since they were first introduced in early s. Using them, it has become so much easier to treat several dermatoses which otherwise were the cause of significant morbidity among people.
However, over the years it has become increasingly apparent that TC are being abused by doctors and patients alike. Apart from the well-known indications such as psoriasis, atopic dermatitis, vitiligo, lichen planus, lichen simplex chronicus, discoid lupus erythematosus, etc. This can buy time and hold patient a while longer more so with a nonspecialist.
Studies in patients presenting with steroid-related eruptions have shown that there are several nonmedical advisers like friends, neighbors, beauticians, barbers, etc. Prescription sharing with relatives and friends on the presumption that similar looking skin problems can be self-treated by simple prescription copying is rampant.
To compound this problem, there is easy availability of these drugs almost for the asking without a valid prescription at every chemist shop. Moreover, store pharmacists also double up as doctors doling out advice about which TC to use.
These instances, although reported from many places worldwide,[ 7 — 9 ] have significant impact in our country of a billion plus people with an adverse specialist-to-patient ratio. The awareness of this significant problem has led to a flurry of activity as evidenced by discussions about TC misuse by dermatologists at various forums in the country and abroad. As a dermatologist, the onus of responsibility lies on us, for whom these drugs are a strong weapon to fight many skin diseases, to correctly educate the society including our non-dermatologist medical fraternity about ethical and rational use of TC.
The primary goal underlying all ethical issues in health care, in our case the use of TC, is to see that the knowledge gained through research should benefit and not cause harm to the society and that knowledge should be disseminated correctly. A bunch of TC is available for the management of dermatoses. A basic understanding of them certainly helps clinicians to select appropriate preparations that maximize therapeutic efficacy and minimize the potential for adverse effects.
For successful treatment with TC, key factors to be considered are accurate diagnosis, selecting the correct drug, keeping in mind the potency, delivery vehicle, frequency of application, duration of treatment and adverse effects, and proper patient profiling. The TC are effective for skin conditions that are characterized by hyper-proliferation, inflammation, and immunologic involvement.
It is important to prescribe TC only after having a correct diagnosis in a patient and for those dermatoses where there is reasonable evidence of efficacy. We should strongly resist the temptation to use TC for everything that we do not understand or where nothing else is working. This may provide temporary benefits, but makes diagnosis even more difficult for the next time apart from exposing the patient to the risk of adverse effects.
Knowing the correct indication, different strengths of topical steroids may be used to treat different phases of the disease. Potency is the amount of drug required to produce a desired therapeutic effect. The potency of TC is usually assessed by measurement of vaso-constrictive properties. This is a useful but not perfect method for predicting the clinical effectiveness of steroids.
Since the time hydrocortisone was first shown to be clinically effective as a topical preparation in , the molecule has been structurally modified by halogenation, methylation, acetylation, esterification, etc.
Modifications such as halogenation increase the potency but also the adverse effects. TC are divided into four groups according to their potency in keeping with the British National Formulary BNF , while American system classifies them into seven classes,[ 23 ] with class I being the super potent or ultra potent and class VII represent the least potent [ Table 2 ].
Although a thorough knowledge of drugs in each class may be ideal, practically a physician should become familiar with one or two agents in each category of potency to safely and effectively treat steroid-responsive skin conditions.
As a general rule, low potency steroids are the safest agents for long-term use, on large surface areas, on the face, or on areas with thinner skin and for children.
More potent TC are helpful for severe disease and for thicker skin of palms and soles. High and ultra-high potency steroids should not be used on the face, groin, axillae, and under occlusion; except in rare situations and for short duration. TC are available in several formulations and with varying strength, which may differ in potency based on their vehicle in which they are formulated.
The selection of vehicle depends on the type of lesions and the anatomical region. They are available in ointments, creams, gels, lotions, solutions, etc. Ointments provide more lubrication and occlusion than other preparations and are the most useful for treating dry and thick, hyper-keratotic lesion. Their occlusive nature adds on to improve steroid absorption.
However, they should not be used on hairy area and may cause maceration and folliculitis, if used in intertriginous areas and their greasy nature may result in poor patient satisfaction and compliance. Creams have good lubricating qualities and their ability to vanish into the skin make them cosmetically appealing. For acute exudative inflammation and in intertriginous areas, creams are better for their nonocclusive and drying effect.
Creams are generally less potent than ointment of the same medication, but they often contain preservatives which can cause irritation, stinging, and allergic reaction. Lotion and gels are the least greasy and occlusive of all topical steroid vehicles. Lotions are useful for hairy areas because they penetrate easily and leave little residue.
Gel dry quickly and can be applied on the scalp or other hairy areas as they do not cause matting. Occlusion increases steroid penetration and can be used in combination with all vehicle.
Simple plastic dressing results in a seven-fold increase in steroid penetration compared with dry skin. Applying a topical steroid after a shower or bath improves its effectiveness due to hydration.
Sometime the most well-meaning dermatologist and other medical care givers fail to spend enough time with the patient. This is because without proper guidance, patients differ greatly in the way they would use TC in terms of the amount, the frequency, and duration of use thus causing differences in the efficacy and the harm profile they experience. Rational use involves putting across proper guidelines in this area. A FTU is defined as the amount that can be squeezed from the finger tip to the first crease of the finger with a 5 mm diameter nozzle.
Using a standard nozzle tube, one FTU equals 0. The use of FTU is greatly promoted worldwide to reduce the variation in uses of TC and to encourage adherence to therapy. The recommended doses in terms of FTU will depend on which part of the body is being treated.
This is because the skin is thinner in certain parts of the body and more sensitive to the effects of TC. In practice once or twice daily application is recommended for most conventional TC preparations. On the other hand, frequent use of TC leads to several local and systemic side effects. A change to once daily application was suggested several years ago. Perhaps the biggest barrier to this has been our habit.
It is also a well known fact that the stratum corneum acts as a reservoir for TC. An ultra-potent TC such as clobetasol propionate 0. Once a condition is in remission or under desired control weekend TC separated by weekdays of emollients or steroid sparing agents also is quite rewarding.
By doing so, the benefits of the therapy can be maximized, the cost can be reduced, and local and systemic adverse effects of TC can be decreased.
For an individual patient, the optimal dosing schedule can be determined by trial and error, titrating to the minimum frequency of application that still provides relief.
Generally most of the TC, regardless of the potency, should not be used for more than 2—4 weeks duration at a stretch. If there is worsening of the lesions or no change noticed, the product needs to be discontinued and re-evaluation of the diagnosis is needed. Super potent and potent preparations are specifically recommended for a maximum duration of only 2 weeks followed by a tapering regimen for maintenance to avoid adverse effects. TC are used primarily for their anti-inflammatory properties.
Paradoxically, the same mechanisms which mediate their anti-inflammatory properties and underlie their usefulness are also responsible for their adverse effects. They are encountered more frequently and have become more prevalent with the introduction of high potency TC.
These include, atrophy, striae, telengiectasis, purpura, hypo-pigmentation, acneiform eruptions, rosacea-like perioral and periorbital dermatitis, and hypertrichosis. A typical example of this is seen when someone applies a TC to an itchy groin rash.
If this is a fungal infection, the rash gets redder, itchier, and spread more extensively than a typical fungal infection. The resulting rash is a bizarre pattern of widespread inflammation with pustules called tinea incognito [ Figure 1 ].
Due to inappropriate and uncontrolled use of TC, an under reported and under stressed entity has evolved, namely TC addiction. Convincing arguments have been put to consider several erythema syndromes such as red face syndrome, post-peel erythema, red scrotal syndrome, vulvodynia, perianal atrophoderma, chronic actinic dermatitis, and chronic recalcitrant eczemas under the umbrella of steroid addiction. Patients are mostly females who keep on using the steroidal cream till they get magical response and continue it later to prevent rebound flare till finally the lesions become persistent [ Figure 2 ].
Topically applied high and ultra high potency TC can be absorbed well enough to cause systemic side-effects. Hypothalamic-pituitary-adrenal suppression, glaucoma, hyperglycemia, hypertension, and other systemic side-effects have been reported, though rare. Most of the adverse reactions may be reversible to some extent upon discontinuation, with the exception of atrophic striae [ Figure 3 ], which are not reversible.
It has been suggested that corticosteroid effects are due to their action on gene expression by two different mechanisms; transrepression responsible for most therapeutic effects and transactivation which mediates a large proportion of adverse effects.
Selective novel glucocorticoid receptor agonists are being developed that exhibit relative dissociation between transrepression and transactivation. This may in future lead to development of a novel class of TC devoid of significant adverse effects. It is the tolerance that skin develops to the vasoconstrictive action of TC.
After repeated use of topical steroids, the capillaries in the skin do not constrict well, requiring higher dose or more frequent application of the steroid. The ability of the blood vessels to constrict returns four days after stopping therapy. It is now suggested that either poor patient compliance or the natural course of disease activity unrelated to the therapy may be the main reason behind tachyphylaxis.
If a TC loses its effectiveness, it should be discontinued for 4—7 days and then restarted. Contact dermatitis due to TC is not uncommon. The estimated prevalence was found to be in the range of 0. It should be considered whenever there is no satisfactory resolution, or worsening of lesions after excluding exacerbation of an undiagnosed infection.
Sometimes worsening of a longstanding chronic expanding eczematous rash despite TC use may be due to the phenomenon of corticosteroid addiction, a well-defined entity which may be mediated by an underlying increase in serum nitric oxide levels. A skin patch test can be used to detect and confirm sensitivity to corticosteroids.