Topical steroids

Topical steroids have revolutionized the practice of dermatology since they were introduced in the late 1950s. They are effective anti-inflammatory preparations used to control eczema/dermatitis and many other skin conditions. They are also called topical corticosteroids or cortisone.

Like all medications, topical (cortico)steroids are associated with potential adverse effects (side effects) especially if they are used incorrectly.

The topical steroids can be divided up into four groups according to their strength. As a general rule, use the weakest possible steroid that will do the job. However, sometimes it is appropriate to use a potent preparation for a short time to make sure the skin condition clears completely.

Topical steroids available in New Zealand

Note:

Topical steroids are prescription medicines regulated by Health Authorities. The products listed here are the generic (and trade) names of those available in New Zealand currently (July 2007). The products available in other countries may be different. For example, in the USA, the classification of topical steroids places them in seven potency classes. Seek the advice of a pharmacist or your own medical practitioner if you require more information.

Class 1

Very potent (up to 600 times as potent as hydrocortisone)

• Clobetasol propionate (Dermol™ Cream/Ointment)
• Betamethasone dipropionate (Diprosone™ OV Cream/Ointment)

Class 2

Potent (100-150 times as potent as hydrocortisone)

• Betamethasone valerate (Beta™ Cream/Ointment/Scalp Application, Betnovate™ Lotion/C Cream/C Ointment, Fucicort™)
• Betamethasone dipropionate (Diprosone™ Cream/Ointment, Daivobet® 50/500 Ointment/Gel)
• Diflucortolone valerate (Nerisone™ C/Cream/Fatty Ointment/Ointment)
• Hydrocortisone 17-butyrate (Locoid™ C/Cream/Crelo Topical Emulsion/Lipocream/Ointment/Scalp Lotion)
• Mometasone furoate (Elocon™ Cream/Lotion/Ointment)
• Methylprednisolone aceponate (Advantan™ Cream/Ointment)

Class 3

Moderate (2-25 times as potent as hydrocortisone)

• Clobetasone butyrate (Eumovate™ Cream)
• Triamcinolone acetonide (Aristocort™ Cream/Ointment, Viaderm KC™ Cream/Ointment, Kenacomb™ Ointment)

Class 4

Mild

• Hydrocortisone 0.5-2.5% (DermAid Cream/Soft Cream, DP Lotion-HC 1%, Skincalm, Lemnis Fatty Cream HC, Pimafucort Cream/Ointment)

Topical steroids are also available in combination with salicylic acid to enhance penetration, and with antibacterial and antifungal agents.

Skin absorption of topical steroids

Steroids are absorbed at different rates from different parts of the body. A steroid that works on the face may not work on the palm. But a potent steroid may cause side effects on the face. For example:

• Forearm absorbs 1%
• Armpit absorbs 4%
• Face absorbs 7%
• Eyelids and genitals absorb 30%
• Palm absorbs 0.1%
• Sole absorbs 0.05%

Side effects of topical steroids

Internal side effects

If more than 50g of clobetasol propionate, or 500g of hydrocortisone is used per week, sufficient steroid may be absorbed through the skin to result in adrenal gland suppression and/or eventually Cushing's syndrome.

• Adrenal Gland Suppression.
  Topical steroids can suppress the production of natural steroids, which are essential for healthy living. Stopping the steroids suddenly may then result in illness.
  
• Cushing's Syndrome If large amounts of steroid are absorbed through the skin, fluid retention, raised blood pressure, diabetes etc. may result.

Skin side effects

Local side effects of topical steroids include:

• Skin thinning (atrophy) and stretch marks (striae).
• Easy bruising and tearing of the skin.
• Perioral dermatitis (rash around the mouth).
• Enlarged blood vessels (telangiectasia).
• Susceptibility to skin infections.
• Disguising infection e.g. tinea incognito.
• Allergy to the steroid cream.

The risk of these side effects depends on the strength of the steroid, the length of application, the site treated, and the nature of the skin problem. If you use a potent steroid cream on your face as a moisturiser, you will develop the side effects within a few weeks. If you use 1% hydrocortisone cream on your hands for 25 years, you will have done no harm at all (except for having wasted a lot of money!)

Adverse effects of topical steroids

Bruising	Skin thinning
Prominent capillaries	Stretch marks

How to use topical steroids

Ask for specific instructions how to use your topical steroid(s). See DermNet's information about fingertip units. Which one, where, when, how often and for how long? Cream, ointment or lotion? This is particularly important if:

• You are using strong steroids over large areas of your body.
• You have been asked to use plastic to cover treated areas (occlusion).
• Your skin condition persists for more than two or three weeks.
• You are a child.

Topical steroids are very effective medications. They work by reducing inflammation, and when used correctly are very safe. They should not be used as bleaching creams.

Apply topical steroids only to the areas affected by the skin disease, and generally only once or twice daily. If your skin is dry, apply an emollient frequently.