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Topical Corticosteroid

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Topical Corticosteroid, Topical Steroid, Clobetasol Propionate, Betamethasone Dipropionate, Triamcinolone Acetonide, Fluocinolone Acetonide, Hydrocortisone Cream, Hydrocortisone Topical, Halobetasol Propionate, Ultravate, Temovate, Diprolene, Diflorasone diacetate, Psorcon, Amcinonide, Cyclocort, Diprosone, Mometasone furoate, Elocon, Florone, Fluocinonide, Lidex, Maxiflor, Desoximetasone, Topicort, Halcinonide, Halog, Hydrocortisone valerate, Westcort, Kenalog, Flurandrenolide, Cordran, Betamethasone valerate, Valisone, Hydrocortisone butyrate, Locoid, Flucinolone Acetonide, Synalar, Alclometasone dipropionate, Aclovate, Desonide, Desowen

  • Background
  1. Once daily dosing is as effective as 2-3 times daily dosing
    1. Increased frequency does not improve outcomes and decreases patient compliance
    2. Reapply after washing skin
    3. Green (2005) Br J Dermatol 152:130-41 [PubMed]
  2. Adjunctive measures: Occlusion
    1. Increases potency of steroid 10 fold
    2. Apply shower cap, plastic bag, vinyl suit, bandages or gloves
    3. Use for stubborn areas
  3. Vehicle
    1. See Preparation Bases
    2. Ointments (petroleum based)
      1. Thick, lubricating agents best applied to dry, hyperkeratotic smooth, non-hairy skin
      2. Least likely of topical agents to result in reaction (most inert with least additives)
      3. More potent than creams
      4. More greasy than creams
        1. Avoid on oozing lesions
        2. Avoid in intertriginous folds (e.g. axilla, groin) due to risk of maceration
        3. Avoid in moist or hot environment
    3. Creams
      1. Mixture of water and oils
      2. Less occlusive and more drying than ointments
      3. Often contain additives (e.g. Alcohol) which may be irritating
      4. Preservatives may result in Contact Dermatitis
    4. Lotions
      1. Higher water content than creams
      2. Least potent, least occlusive and least hydrating of vehicles
      3. Best used on hairy areas
    5. Gels
      1. Water-based with rapid drying from skin, and with minimal residue
      2. Sting when applied to inflamed or fissured skin
      3. Best used on hairy areas, or for its drying effect
    6. Foams
      1. Best used on scalp and other hairy regions (e.g. beard)
    7. Solutions, Shampoos and Sprays
      1. Best used on thick hair regions
      2. Many solutions are Alcohol based and may irritate inflamed or fissured skin
  4. Potency
    1. Potency is based on Vasoconstriction assay (degree of Vasoconstriction with steroid application)
    2. Tachyphylaxis (decreased effect with prolonged use) does not typically occur
    3. Ointments are typically considered more potent than creams and lotions
      1. However, efficacy is typically equal among Preparation Bases
      2. Feldman (2005) Curr Ther Res Clin Exp 66(3): 154-71 [PubMed]
      3. Zivkovich (2009) J Drugs Dermatol 8(6): 570-2 [PubMed]
    4. Topical Corticosteroids are divided into 7 classes
      1. Class 1: Very high potency
      2. Class 7: Very low potency
  5. Quantity to prescribe (10 day supply for twice daily dosing)
    1. See Topical Medication Quantity
    2. Face and neck
      1. Finger Tip units: 2.5
      2. Adult: 30 g
      3. Child: 15 g
      4. Infant: 7.5 g
    3. Hand (both sides)
      1. Finger Tip units: 1
      2. Adult: 15 g
      3. Child: 7.5 g
      4. Infant: 3.5 g
    4. Foot (both sides)
      1. Finger Tip units: 2
      2. Adult: 30 g
      3. Child: 15 g
      4. Infant: 7.5 g
    5. Arm
      1. Finger Tip units: 3
      2. Adult: 30 g
      3. Child: 15 g
      4. Infant: 7.5 g
    6. Leg
      1. Finger Tip units: 6
      2. Adult: 60 g
      3. Child: 30 g
      4. Infant: 15 g
    7. Trunk (front or back)
      1. Finger Tip units: 7
      2. Adult: 100 g
      3. Child: 50 g
      4. Infant: 25 g
    8. Body
      1. Adult: 300 g
      2. Child: 150 g
      3. Infant: 75 g
  6. Maximal Duration
    1. Face, groin and intertriginous areas (skin folds)
      1. Limit duration to 1-2 weeks at a time
    2. Very high potency (Class 1)
      1. Avoid use longer than 3 weeks
    3. Medium to high potency (Class 2-6)
      1. Avoid use longer than 12 weeks
    4. Low potency (Class 7)
      1. No specific maximal duration defined
  7. References
    1. Buys (2007) Am Fam Physician 75:523-8 [PubMed]
  • Risk Factors
  • Adverse Effects
  1. High potency Corticosteroids (esp. class 1-2)
  2. Young children
  3. Thin skin (e.g. face, intertriginous areas)
  4. Frequent or prolonged Topical Corticosteroid use
  • Example
  • Lower cost, generic steroids
  1. Level 1: Clobetasol Propionate 0.05% ointment (price jump to $200 for 45 g in 2017)
  2. Level 2: Betamethasone Dipropionate 0.05% ointment
  3. Level 3: Betamethasone Dipropionate 0.05% cream
  4. Level 4: Triamcinolone Acetonide 0.1% ointment
  5. Level 5: Triamcinolone Acetonide 0.1% ointment
  6. Level 6: Fluocinolone Acetonide 0.01% cream
  7. Level 7: Hydrocortisone 1% cream
  • Preparations
  • Level 1 (Ultra-High Potency)
  1. Betamethasone Dipropionate augmented (Diprolene) 0.05% cream and ointment
  2. Clobetasol Propionate (Temovate) 0.05% cream, ointment, lotion, gel, foam, solution, Shampoo, spray cream
  3. Diflorasone diacetate (Psorcon) 0.05% ointment
  4. Flucinonide (Lidex) 0.1% cream
  5. Flurandrenolide 4 mcg/cm2 tape
  6. Halobetasol Propionate (Ultravate) 0.05% cream and ointment
  • Preparations
  • Level 2 (Very High Potency)
  1. Halcinonide (Halog) 0.1% cream
  2. Amcinonide (Cyclocort) 0.1% ointment
  3. Betamethasone Dipropionate augmented (Diprolene AF) 0.05% cream
  4. Betamethasone Dipropionate (Diprosone) 0.05% ointment
  5. Mometasone furoate (Elocon) 0.1% ointment
  6. Diflorasone diacetate (Florone) 0.05% ointment
  7. Fluocinonide (Lidex) 0.05% cream, gel, and ointment
  8. Diflorasone diacetate (Maxiflor) 0.05% ointment
  9. Desoximetasone (Topicort) 0.25% cream and ointment
  10. Desoximetasone (Topicort) 0.05% gel
  • Preparations
  • Level 3 (High Potency)
  1. Halcinonide (Halog) 0.1% ointment, Emollient, cream
  2. Triamcinolone Acetonide (Aristocort A) 0.1% ointment
  3. Amcinonide (Cyclocort) 0.1% cream and lotion
  4. Betamethasone Dipropionate (Diprosone) 0.05% cream
  5. Diflorasone diacetate (Florone) 0.05% cream
  6. Fluocinonide (Lidex-E) 0.05% cream
  7. Diflorasone diacetate (Maxiflor) 0.05% cream
  8. Fluticasone propionate (Cutivate) 0.005% ointment
  • Preparations
  • Level 4 (Medium-High Potency)
  1. Hydrocortisone valerate (Westcort) 0.2% ointment
  2. Triamcinolone Acetonide (Kenalog) 0.1% cream
  3. Flurandrenolide (Cordran) 0.05% ointment
  4. Flucinolone Acetonide (Synalar) 0.025% ointment
  5. Mometasone furoate (Elocon) 0.1% cream
  • Preparations
  • Level 5 (Medium Potency)
  1. Hydrocortisone valerate (Westcort) 0.2% cream
  2. Triamcinolone Acetonide (Kenalog) 0.1% lotion
  3. Flurandrenolide (Cordran) 0.05% cream
  4. Betamethasone Dipropionate (Diprosone) 0.05% lotion
  5. Betamethasone valerate (Valisone): 0.1% cream, lotion
  6. Hydrocortisone butyrate (Locoid) 0.1% cream
  7. Flucinolone Acetonide (Synalar) 0.025% cream
  8. Fluticasone propionate (Cutivate) 0.05% cream
  • Preparations
  • Level 6 (Low Potency)
  1. Alclometasone dipropionate (Aclovate) 0.05% ointment and cream
  2. Fluocinolone Acetonide (Synalar) 0.01% solution and cream
  3. Desonide (Desowen) 0.05% cream and ointment
  • Preparations
  • Level 7 (Lowest Potency)
  1. Hydrocortisone 1%, 2.5% lotion, cream, ointment,
  1. High potency Corticosteroids (Level 1-3)
    1. Alopecia Areata
    2. Atopic Dermatitis (refractory cases)
    3. Bullous Pemphigoid
    4. Dermatitis in regions of thick skin (e.g. palms, soles)
    5. Discoid Lupus
    6. Dyshidrotic Eczema (esp. hands, severe cases)
    7. Eczematous Dermatitis (severe cases)
    8. Hyperkeratotic Eczema
    9. Labial Adhesions
    10. Lichen Planus
    11. Lichen Sclerosus (skin)
    12. Lichen Simplex Chronicus
    13. Melasma
    14. Nummular Eczema
    15. Poison Ivy (severe cases)
    16. Psoriasis
    17. Vitiligo
  2. Medium potency Corticosteroids (Level 4-5)
    1. Asteatotic Eczema
    2. Atopic Dermatitis
    3. Dermatitis (severe)
    4. Infantile Acropustulosis
    5. Intertrigo (short-term use for severe cases)
    6. Lichen Sclerosus (vulvar)
    7. Nummular Eczema
    8. Perianal inflammation (severe cases)
    9. Scabies (only after the anti-Scabies agent has been used)
    10. Seborrheic Dermatitis
    11. Severe Intertrigo
    12. Stasis Dermatitis
  3. Low potency Corticosteroids (Level 6-7)
    1. Dermatitis (face, Eyelids, diaper area)
    2. Intertrigo
    3. Perianal inflammation
    4. Phimosis
  4. References
    1. Ference (2009) Am Fam Physician 79(2): 135-40 [PubMed]
  1. Low potency Topical Corticosteroids
    1. Face
    2. Groin
    3. Intertriginous areas
  2. Mid-potency Topical Corticosteroids
    1. Thin skin trunk areas
    2. Extremity lesions
  3. High potency Topical Corticosteroids
    1. Thick skin trunk areas
    2. Extremity lesions
  4. Very high or super-potent Corticosteroids
    1. Very thick-skinned areas
    2. Palms and soles
  • Adverse Effects
  • Topical Corticosteroids
  1. Percutaneous absorption with systemic steroid effects
    1. Systemic effects are uncommon with Topical Corticosteroids
    2. Risk Factors for systemic effects
      1. Very high potency and high potency Topical Corticosteroids (level 1-3)
      2. Prolonged use of higher potency Topical Corticosteroids >2-4 weeks
      3. Large surface area of Topical Corticosteroid application
      4. High potency Corticosteroid on thin skin (e.g. face, axilla, groin)
      5. Children and Elderly (higher absorption)
    3. Mitigation of systemic effects
      1. Limit high potency Corticosteroids to 2-4 weeks of use
      2. Consider pulse dosing of Topical Corticosteroid (2 weeks on, 1 week off)
      3. When appropriate, use lower potency Corticosteroids
    4. Systemic Corticosteroid Effects
      1. Cushing Syndrome
      2. Adrenal suppression
      3. Growth Delay
      4. Steroid-Induced Hyperglycemia
      5. Aseptic Necrosis of the Femoral Head
      6. Hypertension
      7. Peripheral Edema
  2. Skin atrophy
    1. Skin fragility
    2. Easy Bruising
    3. Pigment change (Hypopigmentation, Hyperpigmentation)
    4. Petechiae, Purpura and telangiectasias
    5. Skin Ulcers
    6. Striae formation
  3. Rebound papular dermatitis after medium-high potency
    1. Avoid high potency steroid on genital or face
  4. Secondary or provoked Skin Infections
    1. Masked Tinea Infection
    2. Granuloma gluteale infantum
  5. Eye affects (if exposed)
    1. Glaucoma
    2. Cataracts
  6. Corticosteroid withdrawal effects (rebound inflammation after stopping steroid)
    1. Most common on the face and genitalia
    2. Erythema, edema and skin Scaling
    3. Stinging and burning
    4. Papules and Pustules
  7. Other effects
    1. Acne Rosacea
    2. Acne Vulgaris
    3. Contact Dermatitis
    4. Delayed Wound Healing
    5. Hypertrichosis
    6. Periocular dermatitis
    7. Photosensitivity
    8. Superficial Folliculitis
  8. References
    1. Hengge (2006) J Am Acad Dermatol 54(1): 1-15 [PubMed]
  • References
  1. (2021) Presc Lett 28(5): 29
  2. (2018) Presc Lett 25(1): 5
  3. Kaplan (2001) CMEA Medicine Lecture, San Diego
  4. Stacey (2021) Am Fam Physician 103(6): 337-43 [PubMed]