contagiosum, fungal infections, and viral infections.
General Recommendations for Treatment of Dry Skin
Keep room temperature as low as comfortable to prevent sweating and water loss from the skin.
immediately apply an emollient. When the skin is soaked for 5 to 10 minutes, the stratum corneum can
the water in the skin and reduce dryness.
ineffective, switching to a product with less glycerin and more oil may resolve the dryness.
Topical corticosteroids are classified into potency categories (Table 39-7). The
relative potency assigned to a topical corticosteroid is determined by the ability of
the preparation to penetrate the skin after release from the vehicle, the intrinsic
activity of the corticosteroid at the receptor, and the rate of clearance from the
10 Activity of corticosteroids may be enhanced by the use of a more
occlusive vehicle, the addition of penetration-enhancing substances (i.e., petrolatum,
propylene glycol), and modifications of the steroid molecule. Hydrocortisone has
been modified in several ways to enhance potency. The addition of a fluorine atom at
the 6, 9, and 21 positions protects the steroid ring from metabolic conversion,
resulting in more potent activity. The addition of a double bond between the first and
second carbon atoms slows metabolism, increasing duration of action. The
introduction of an acetonide bond or lipophilic ester groups increases skin
penetration. Many newer topical corticosteroids have incorporated one or more of
these molecular changes, resulting in increased-potency agents and a growing
Topical corticosteroids penetrate into the stratum corneum by passive diffusion,
which varies considerably, depending on thickness of the stratum corneum over the
part of the body to which the preparation is applied. When a standard hydrocortisone
preparation was applied to various parts of the body, absorption was found to be
0.14% on the plantar surface of the foot, 1% on the forearm, 4% on the scalp, 7% on
the forehead, 13% on the cheeks, and 36% on the scrotum. Because penetration is
high in the groin, axillae, and face, lower-potency nonfluorinated topical
preparations such as hydrocortisone 0.5% to 1% should be used on these areas.
areas where penetration is poor, owing to thicker stratum corneum, such as the
elbows, knees, palms, or soles, higher-potency preparations should be used.
Topical Corticosteroid Preparations by Stoughton–Cornell Classification of
Corticosteroid Example Brand Name(s) Vehicle
1 (Most Potent) no more than 2 weeks’ use
Betamethasone dipropionate Diprolene 0.05% Ointment, optimized vehicle
Clobetasol propionate Temovate 0.05% Cream, ointment, optimized vehicle
Diflorasone diacetate Psorcon 0.05% Ointment
Halobetasol propionate Ultravate 0.05% Cream, ointment
Amcinonide Cyclocort 0.1% Cream, lotion, ointment
Betamethasone dipropionate Diprolene AF 0.05% Cream
Betamethasone dipropionate Diprosone 0.05% Ointment
Desoximetasone Topicort 0.25% Cream, ointment
Desoximetasone Topicort 0.05% Gel
Diflorasone diacetate Florone, Maxiflor 0.05% Ointment
Fluocinonide Lidex 0.05% Cream, ointment, gel
Triamcinolone acetonide Kenalog 0.5% Cream, ointment
Amcinonide Cyclocort 0.1% Cream, lotion
Betamethasone Benisone, Uticort 0.025% Gel
Betamethasone benzoate Topicort LP 0.05% Cream (emollient)
Betamethasone dipropionate Diprosone 0.05% Cream
Betamethasone valerate Valisone 0.1% Ointment
Diflorasone diacetate Florone, Maxiflor 0.05% Cream
Fluocinonide Cutivate 0.005% Ointment
Fluticasone propionate Lidex E 0.05% Cream
Halcinonide Halog 0.1% Ointment
Triamcinolone acetate Aristocort A 0.1% Ointment
Triamcinolone acetate Aristocort HP 0.5% Cream
Betamethasone benzoate Benisone, Uticort 0.025% Ointment
Betamethasone valerate Valisone 0.1% Lotion
Desoximetasone Topicort-LP 0.05% Cream
Fluocinolone acetonide Synalar-HP 0.2% Cream
Fluocinolone acetonide Synalar 0.025% Ointment
Flurandrenolide Cordran 0.05% Ointment
Triamcinolone acetonide Aristocort, Kenalog 0.1% Ointment
Betamethasone benzoate Benisone, Uticort 0.025% Cream
Betamethasone dipropionate Diprosone 0.02% Lotion
Betamethasone valerate Valisone 0.1% Cream
Clocortolone Cloderm 0.1% Cream
Fluocinolone acetonide Synalar 0.025% Cream
Flurandrenolide Cordran 0.05% Cream
Fluticasone propionate Cutivate 0.05% Cream
Prednicarbate Dermatop 0.1% Cream
Triamcinolone acetonide Aristocort 0.25% Cream
Alclometasone dipropionate Aclovate 0.05% Ointment
Betamethasone valerate Valisone 0.1% Lotion
Fluocinolone acetonide Synalar 0.01% Solution
Triamcinolone acetonide Kenalog 0.1% Cream, lotion
a Generic 0.5%, 1.0%, 2.5% Cream, ointment
Dexamethasone Decadron 0.1% Cream
aNonfluorinated corticosteroid.
The stratum corneum acts as a reservoir, precluding the need for more than twice
daily application. In low-potency preparations, this reservoir effect persists for
several days, and with the most potent preparations under occlusion, the effects may
9–13 The clinical implication of this reservoir effect on
chronic conditions is a cumulative effect with repeated application of topical
corticosteroids. As a result, the number of applications per day can be reduced, and
less potent preparations can be used after the acute inflammatory process has been
brought under control. It also allows less frequent administration to maintain
For A.J, a high-potency cream (class 2 or 3 as listed by Stoughton–Cornell class
of corticosteroid potency in Table 39-7) should be used because the thicker stratum
corneum over the elbow, the presence of scales and a raised plaque decreases
When equal amounts of a corticosteroid are incorporated into ointments, gels,
creams, and lotion bases, the gel and ointment preparations are generally more active
9–13 However, with the increased use of optimized vehicles,
that rule is not as true as in the past. The addition of certain substances enhances
penetration and potency. Using these principles, pharmaceutical manufacturers have
increasingly developed optimized vehicles that maximize diffusion of individual
corticosteroids into the stratum corneum. Unfortunately, these optimized bases may
be labeled as ointments, creams, or gels. Therefore, for new products, the only
reliable way to ascertain potency is to consult the manufacturer’s literature for its
Stoughton–Cornell classification. Increasing the concentration of a corticosteroid in a
preparation also increases its potency, but not in a linear fashion.
therapy be used? What complications could develop from occlusion? How should the use of occlusion be
Occlusion increases the hydration of the skin and resultant absorption of
corticosteroid preparations, thus producing a heightened therapeutic effect.
Generally, occlusion can be accomplished by the following: (a) selecting an
ointment-based corticosteroid, (b) applying a nonmedicated ointment base over a
corticosteroid preparation (gel, cream, lotion, or aerosol), 30 minutes after applying
the corticosteroid, or (c) by enveloping the medicated area with plastic (e.g., plastic
wrap, gloves, or plastic suit). Occlusion is best used for chronic lesions that are thick
and scaly, in which drug absorption is impaired, such as psoriasis. Increasing the
hydration of the skin (with a shower or bath) also increases the effects of medications
immediately applied after the bath or shower. An appropriate recommendation for
A.J. would be fluocinonide ointment 0.05% applied twice daily to only the psoriatic
4,6,9–13 For other conditions, for example, atopic dermatitis, several hours of
occlusion are all that are necessary to increase potency, these relatively short periods
of occlusion can be clinically useful. Occlusion can be uncomfortable and can lead to
sweat retention and an increased risk of bacterial and fungal infections. To reduce
these problems and the chances of systemic adverse effects, occlusion should not be
maintained for more than 12 hours in a 24-hour period. Occlusion should not be used
for acute lesions, which already have increased absorptive capability and need the
vasoconstrictive effects of cooling first.
Pharmacists and practitioners tend to underappreciate that both cloth and
disposable diapers are powerful occlusive devices. Therefore, only low-potency
nonfluorinated topical corticosteroids should be used in the diaper area for no more
than 24 to 48 hours in the rare instances of severe diaper dermatitis not responding to
conservative treatment. Use of topical corticosteroids to enhance the effectiveness of
antifungals in the face of diaper dermatitis complicated by fungal infection is only
theoretic and does not enhance the efficacy of anticandidal antifungals, but does
increase the risk of local, potentially irreversible disfiguring local adverse effects of
Although relatively infrequent, both localized (i.e., at the application site) and
systemic adverse effects (from percutaneous
absorption) can be caused by topical corticosteroids. The risks for adverse reactions
are influenced by the potency of preparation used, frequency of application, duration
of use, anatomic site of application, and individual patient factors. Any of the
previously discussed factors that increase potency, such as inflammation and
occlusion, increase the chances of adverse effects.
topical corticosteroid for K.L.?
The biggest concern in K.L. is the potential for epidermal and dermal atrophy
(thinning of the skin), telangiectasia (small red or purple clusters of dilated
capillaries), localized fine hair growth, bruising, hypopigmentation, and striae. These
local complications can result from repeated application of topical corticosteroids.
Epidermal changes consisting of a reduction in cell size may begin within several
days of therapy and are generally reversible after therapy is stopped.
(face) and thin-skinned areas (groin) are most vulnerable to dermal and epidermal
Dermal atrophy generally takes several weeks to occur and can be reversed in
some cases, depending on how long the patient has used the corticosteroid, and on
individual host factors such as skin age. Dermal atrophy can be reversible within 2
months after stopping the corticosteroid.
Telangiectasia, which occurs most often on the face, neck, groin, and upper chest,
may not be reversible after stopping corticosteroid therapy. Striae, which occur most
commonly in the cubital and popliteal fossa, groin, axillary, and inner thigh areas, are
12 Fine hair growth may be particularly bothersome to female
patients using corticosteroid preparations on the face. This problem is generally
reversible after stopping therapy. Hypopigmentation, predominantly a problem of
dark-skinned patients, is generally reversible after therapy is discontinued.
Especially in thin-skinned areas such as the face, fluorinated corticosteroids are
more likely to cause these localized reactions because of their increased-potency
than nonfluorinated corticosteroids. Therefore, whenever possible only
nonfluorinated topical corticosteroids should be used in thin-skinned areas for the
shortest possible time. Because the use of corticosteroids is expected to last less than
a week, the risk of developing local complications is minimal with a nonfluorinated
Because the lesions are on the face, a nonfluorinated corticosteroid such as
hydrocortisone valerate or mometasone should be used to minimize the potential for
adverse effects in this thin-skinned area. Although there is minimal oozing and
weeping, his sensitivity to appearance would indicate a cream might be more
minutes after each application. He wants to know whether this is potentially an allergic reaction.
Because of the time course of the burning sensation in L.K. (starting the first day
and lasting only 30 minutes), it is doubtful that he is actually allergic to this product
and points to the cream being the cause. To remedy this situation, L.K. should
continue to apply it and if it continues for the next 24 hours to call again. Creams
applied to inflamed areas can cause burning initially. Because the inflammation
lessens, the burning generally subsides. If the burning persists, an ointment can be
substituted, or the cream. If the reaction continues with a new product, an allergy
workup may be necessary and patch testing could be considered.
Cortisol is endogenously secreted by the adrenal gland and is essential to life. As
a result, allergic reactions to topical corticosteroid preparations are rare. When
allergic symptoms do occur, they are generally not caused by the corticosteroid, but
rather the preservatives (e.g., paraben) or other ingredients in the formulation or the
base (e.g., lanolin). Allergic sensitization can occur within 2 weeks of therapy, but
may be difficult to diagnose because the corticosteroid can modify the allergic
14 One should suspect an allergic reaction if lesions change appearance after
starting therapy, if healing does not occur within the expected time, or if the condition
improves and then abruptly gets worse. In atopic dermatitis, most case reports of
allergic reactions (dryness, itching, burning, or irritation) to topical corticosteroids
14 The use of creams or gels may cause excessive dryness,
burning, and irritation. Switching to an ointment can alleviate those symptoms.
Allergic individuals are more likely to react to the vehicle base than the active
CASE 39-4, QUESTION 3: After several weeks of continuous corticosteroid and adjuvant therapy, K.L.’s
therapy on the face does this represent?
The face is particularly vulnerable to corticosteroid adverse effects because of
12 Acne, acne rosacea, and perioral dermatitis can develop after
several weeks to months of application. Corticosteroid-induced conditions can
generally be distinguished from naturally occurring disorders because lesions are
uniformly at the same level of development throughout the affected area and are
present only in areas treated with the corticosteroid. Generally, steroid acne and
perioral dermatitis resolve after discontinuing the drug. Application of corticosteroid
preparations (particularly the potent preparations) to areas around the eye can lead to
increased intraocular pressure, glaucoma, cataracts, increased risk of ocular mycotic
infections, and exacerbation of preexisting herpes simplex infections.
Because K.L.’s original disorder was also treated with topical selenium sulfide
shampoo to the face and the scalp to suppress the cause of his seborrheic dermatitis,
the corticosteroid can be discontinued.
ADRENAL AXIS SUPPRESSION AND RISK OF INFECTION
Systemic adrenal axis suppression from topically applied corticosteroids appears to
15 or other risk factors are present (Table 39-8).
Although suppression has been reported with use of mild to moderately potent agents,
these cases can be attributed to excessive use or to application of corticosteroids
over large areas of the body for prolonged periods under occlusion. If suppression
does occur, it reverses within 2 to 4 weeks after application is stopped. Patients
using more than 45 g/week of a high-potency corticosteroid are at risk for adrenal
15 Therefore, the use of preparations such as clobetasol should be
limited to no more than 45 g/week for 2 weeks or less. In addition, these preparations
should not be used under occlusion and should be reserved for dermatoses that are
unresponsive to less potent preparations.
Risk Factors for Systemic Adverse Effects from Topical Corticosteroids
Prolonged application (>3–4 weeks)
Weak or moderately strong, 100 g/week without occlusion
Very potent, >45 g/week without occlusion
Very young children and elderly people have very thin epidermis
Presence of penetration-enhancing substances
Because young children absorb corticosteroids to a greater extent than adults, they
have a greater risk of developing adrenal axis suppression and other systemic
15 To reduce this risk, low-potency topical preparations should be
used in children, and their use should be limited to short periods. Patients whose
corticosteroid clearance is impaired (e.g., liver failure) should also use
hydrocortisone and be monitored closely for signs of systemic toxicity.
The risk of developing an Addisonian crisis during surgery or at other times of
stress secondary to adrenal suppression from topical steroids is extremely low.
Patients who have used potent topical corticosteroids over large areas of their bodies
(>30%) or those who have used occlusion are at greater risk (see previous
discussion) and are often given systemic hydrocortisone prophylactically before
PROPER APPLICATION OF TOPICAL CORTICOSTEROIDS
Because overuse of topical corticosteroids leads to local and/or systemic effects and
underuse results in suboptimal treatment, the amount of corticosteroid required to
treat certain anatomic areas of the body has long been an issue of debate and
16,17 To prevent overuse in clinical practice, patients are typically given
subjective instructions to apply topical products “sparingly” or “in a thin layer or
coat” and left up to the patient or caregiver’s interpretation.
The fingertip unit (FTU) was devised as a means of standardizing the way
practitioners and pharmacists alike thought about how to prescribe topical
corticosteroids and counsel patients on appropriate use. One FTU is defined as the
amount of ointment (or other semisolid topical formulation) squeezed from a tube
with a 5-mm diameter nozzle (standard in manufacturing), applied from the first
distal skin crease to the tip of the index finger of an adult.
equivalent to 500 mg of medication. The FTU can serve as a helpful starting point for
how much product is used. Because lesions rarely conform to the exact anatomic
areas in Table 39-9, adjustments need to be made based on the specific area
involved. For example, in an adult with atopic dermatitis on the cubital fossa of both
arms, the table does not provide that exact measurement. Because one FTU covers
both sides of a hand and the cubital fossa is approximately hand-sized, the patient
should be instructed to apply 0.5 FTU to each cubital fossa once or twice daily
depending on the specific preparation. Although use of the FTU concept is not a
panacea, it does provide a more objective benchmark to help patients more
consistently apply the correct amount of product and avoid overuse. Use of the FTU
concept must be accompanied by counseling and reinforcement based on the
individual medication received, size and location of the lesion, and the desired goals
of therapy. In addition, the FTU concept can be used to determine the amount to be
dispensed to cover a treatment period.
Fingertip Unit Charts for Adults and Children
Fingertip unit measures for use in adults
Torso and abdomen (front of trunk) 7
Back and buttocks (back of trunk) 7
Adult fingertip unit measures for use in children (by age of child)
3–6 months 1–2 years 3–5 years 6–10 years
Summary of Principles of Topical Corticosteroid
The following principles are used to guide the choice of agent and application
technique (Table 39-7 and Table 39-9):
Due to the reservoir effect of the stratum corneum, topical corticosteroids should be
applied no more than twice daily. Increasing the application from twice daily to 4
times daily does not produce superior responses, is more expensive, and may
lead to increased frequency of topical and systemic adverse effects.
Preparations should be rubbed thoroughly and, when possible, applied while the
skin contains optimal moisture (e.g., after bathing and drying off).
the skin increases percutaneous absorption and the resultant therapeutic effect of
Appropriate-strength preparations should be used to control the condition. For
maintenance, most dermatologic conditions requiring topical corticosteroids can
be managed with medium- or low-potency corticosteroid preparations (i.e., 1%
hydrocortisone or a low-strength fluorinated corticosteroid such as triamcinolone
Occluded areas and certain, thin-skinned areas of the body, such as the face and
flexures, are more prone to the development of adverse effects.
corticosteroids must be used on the face flexures or other thin-skinned areas,
hydrocortisone or other nonfluorinated topical corticosteroids should be used to
reduce the probability of adverse effects. These nonfluorinated corticosteroid
products are highlighted in Table 39-6.
Children, elderly patients, and patients with liver failure are at risk for systemic
corticosteroid toxicities. In addition, patients who use the highest-potency
preparations for longer than 2 weeks are susceptible to percutaneous absorption
and systemic toxicity including Addison syndrome upon sudden
With chronic conditions such as atopic eczema or allergic contact dermatitis, it is
best to discontinue therapy gradually. This reduces the potential for rebound
treat flare-ups during the years.
Atopic dermatitis, a form of eczema, can be acute or subacute, but is more
commonly a chronic pruritic inflammation of the epidermis and dermis.
Approximately two-thirds of the patients have a personal or family history of allergic
rhinitis, eczema, or asthma. Sixty percent of patients are affected within the first year
of life, 30% by 5 years of age, with the remaining 10% experiencing atopic
dermatitis between 6 and 20 years of age. Atopic dermatitis in infants may be a
prelude to the development of other atopic disorders later in life (i.e., allergic
rhinitis or asthma). Presence of these disorders many times is the key to differential
diagnosis. About 80% of patients with atopic dermatitis have a type I
(immunoglobulin E [IgE]-mediated) hypersensitivity reaction occurring because of
the release of vasoactive substances from both mast cells and basophils that have
been sensitized by the interaction of the antigen with IgE. An allergy workup is rarely
helpful in determining the allergen. The disorder affects 0.5% to 1.0% of the general
population, although its prevalence in children is 5% to 10%. In infants and young
children, the dermatitis often occurs on the face and sternal area of the chest. In older
children and adults, it tends to localize to the flexural areas, especially the cubital
and popliteal fossae with the neck and face involved in more severe cases.
Pruritus is the hallmark of atopic dermatitis. Atopic dermatitis has been described
as “the itch that rashes, rather than the rash that itches.” In other words, the itching
untreated atopic dermatitis leads to lichenification of the affected areas. Wool,
detergents, soaps, a change in room temperature, and mental or physical stress can
precipitate itching. Patients tend to have dry skin (xerosis) all over the body. This is
attributable to a reduced water-binding capacity and a higher transdermal water loss.
Xerosis is worsened during periods of low humidity, such as winter in northern
latitudes. Treating the xerosis can prevent or control the disease in mild or episodic
Comments
Post a Comment
اكتب تعليق حول الموضوع