Topical steroid explained

Topical steroids are the topical forms of corticosteroids. Topical steroids are the most commonly prescribed topical medications for the treatment of rash and eczema. Topical steroids have anti-inflammatory properties and are classified based on their skin vasoconstrictive abilities.^[1] There are numerous topical steroid products. All the preparations in each class have the same anti-inflammatory properties but essentially differ in base and price.

Side effects may occur from sudden discontinuation and prolonged, continuous use can lead to skin thinning.^[2] Intermittent use of topical steroids for atopic dermatitis is safe and does not cause skin thinning.^{[3] [4] [5]}

Medical uses

Weaker topical steroids are utilized for thin-skinned and sensitive areas, especially areas under occlusion, such as the armpit, groin, buttock crease, and breast folds. Weaker steroids are used on the face, eyelids, diaper area, perianal skin, and intertrigo of the groin or body folds. Moderate steroids are used for atopic dermatitis, nummular eczema, xerotic eczema, lichen sclerosis et atrophicus of the vulva, scabies (after scabiecide) and severe dermatitis. Strong steroids are used for psoriasis, lichen planus, discoid lupus, chapped feet, lichen simplex chronicus, severe poison ivy exposure, alopecia areata, nummular eczema, and severe atopic dermatitis in adults.^[1]

For treating atopic dermatitis, newer (second generation) corticosteroids, such as fluticasone propionate and mometasone furoate, are more effective and safer than older ones. They are also generally safe and do not cause skin thinning when used in intermittently to treat atopic dermatitis flare-ups. They are also safe when used twice a week for preventing flares (also known as weekend treatment).^{[6] [7] [8]} Applying once daily is enough as it is as effective as twice or more daily application.^[9]

To prevent tachyphylaxis, a topical steroid is often prescribed to be used on a week on, week off routine. Some recommend using the topical steroid for 3 consecutive days on, followed by 4 consecutive days off.^[10] Long-term use of topical steroids can lead to secondary infection with fungus or bacteria (see tinea incognito), skin atrophy, telangiectasia (prominent blood vessels), skin bruising and fragility.^[11]

The use of the finger tip unit may be helpful in guiding how much topical steroid is required to cover different areas of the body.

Adverse effects

See also: Topical steroid addiction.

• Hypothalamic–pituitary–adrenal axis (HPA) suppression^[12]
  • Cushing's syndrome Diabetes mellitus^[13]
• Osteoporosis
• Topical steroid addiction
• Allergic contact dermatitis (see steroid allergy)
• Steroid atrophy
• Perioral dermatitis: This is a rash that occurs around the mouth and the eye region that has been associated with topical steroids.
• Ocular effects: Topical steroid drops are frequently used after eye surgery but can also raise intraocular pressure (IOP) and increase the risk of glaucoma, cataract, retinopathy as well as systemic adverse effects.^[14]
• Tachyphylaxis: The acute development of tolerance to the action of a drug after repeated doses.^[15] Significant tachyphylaxis can occur by day 4 of therapy. Recovery usually occurs after 3 to 4 days' rest. This has led to therapies such as 3 days on, 4 days off; or one week on therapy, and one week off therapy.
• Delivery-related adverse effects
• Other local adverse effects: These include facial hypertrichosis, folliculitis, miliaria, genital ulcers, and granuloma gluteale infantum. Long-term use has resulted in Norwegian scabies, Kaposi's sarcoma, and other unusual dermatosis.^[16]

Safety in pregnancy

Using topical steroids as intended during pregnancy is safe and does not cause miscarriage, birth defects or any pregnancy-related problems.^{[17] [18]}

Classification systems

See also: ATC code D07.

Seven-class System

The U.S. utilizes 7 classes, which are classified by their ability to constrict capillaries and cause skin blanching. Class I is the strongest, or superpotent. Class VII is the weakest and mildest.^[19]

Class I

Very potent: up to 600 times stronger than hydrocortisone

• Clobetasol propionate 0.05% (Dermovate)
• Betamethasone dipropionate 0.25% (Diprolene)
• Halobetasol propionate 0.05% (Ultravate, Halox)
• Diflorasone diacetate 0.05% (Psorcon)

Class II

• Fluocinonide 0.05% (Lidex)
• Halcinonide 0.05% (Halog)
• Amcinonide 0.05% (Cyclocort)
• Desoximetasone 0.25% (Topicort)

Class III

• Triamcinolone acetonide 0.5% (Kenalog, Aristocort cream)
• Mometasone furoate 0.1% (Elocon, Elocom ointment)
• Fluticasone propionate 0.005% (Cutivate)
• Betamethasone dipropionate 0.05% (Diprosone)
• Halometasone 0.05%

Class IV

• Fluocinolone acetonide 0.01–0.2% (Synalar, Synemol, Fluonid)
• Hydrocortisone valerate 0.2% (Westcort)
• Hydrocortisone butyrate 0.1% (Locoid)
• Flurandrenolide 0.05% (Cordran)
• Triamcinolone acetonide 0.1% (Kenalog, Aristocort A ointment)
• Mometasone furoate 0.1% (Elocon cream, lotion)

Class V

• Fluticasone propionate 0.05% (Cutivate cream)
• Desonide 0.05% (Tridesilon, DesOwen ointment)
• Fluocinolone acetonide 0.025% (Synalar, Synemol cream)
• Hydrocortisone valerate 0.2% (Westcort cream)

Class VI

• Alclometasone dipropionate 0.05% (Aclovate cream, ointment)
• Triamcinolone acetonide 0.025% (Aristocort A cream, Kenalog lotion)
• Fluocinolone acetonide 0.01% (Capex shampoo, Dermasmooth)
• Desonide 0.05% (DesOwen cream, lotion)

Class VII

The weakest class of topical steroids. Has poor lipid permeability, and can not penetrate mucous membranes well.

• Hydrocortisone 2.5% (Hytone cream, lotion, ointment)
• Hydrocortisone 1% (Many over-the-counter brands)

Five-class System

Japan rates topical steroids from 1 to 5, with 1 being strongest.

Four-class System

Many countries, such as the United Kingdom, Germany, the Netherlands, New Zealand, recognize 4 classes.^[20] In the United Kingdom and New Zealand I is the strongest, while in Continental Europe, class IV is regarded as the strongest.

Class IV (UK/NZ: class I)

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

• Clobetasol propionate (Dermovate Cream/Ointment, Exel Cream)
• Betamethasone dipropionate (Diprosone OV Cream/Ointment, Diprovate Cream)

Class III (UK/NZ: class II)

Potent (50–100 times as potent as hydrocortisone)

• Betamethasone valerate (Beta Cream/Ointment/Scalp Application, Betnovate Lotion/C Cream/C Ointment, Fucicort)
• Betamethasone dipropionate (Diprosone Cream/Ointment, Diprovate Cream, Daivobet 50/500 Ointment)
• 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)
• Halometasone 0.05%

Class II (UK/NZ: class III)

Moderate (2–25 times as potent as hydrocortisone)

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

Class I (UK/NZ: class IV)

Mild

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

Allergy associations

The highlighted steroids are often used in the screening of allergies to topical steroid and systemic steroids.^[21] When one is allergic to one group, one is allergic to all steroids in that group.

Group A

Hydrocortisone, hydrocortisone acetate, cortisone acetate, tixocortol pivalate, prednisolone, methylprednisolone, and prednisone

Group B

Triamcinolone acetonide, triamcinolone alcohol, amcinonide, budesonide, desonide, fluocinonide, fluocinolone acetonide, and halcinonide

Group C

Betamethasone, betamethasone sodium phosphate, dexamethasone, dexamethasone sodium phosphate, and fluocortolone

Group D

Hydrocortisone 17-butyrate, hydrocortisone-17-valerate, alclometasone dipropionate, betamethasone valerate, betamethasone dipropionate, prednicarbate, clobetasone-17-butyrate, Clobetasol-17 propionate, fluocortolone caproate, fluocortolone pivalate, fluprednidene acetate, and mometasone furoate

History

Corticosteroids were first made available for general use around 1950.^[22]

See also

• Topical medication
• Glucocorticoid
• Corticosteroid
• Retrometabolic drug design

Notes and References

1. Book: Habif, Thomas P. . Clinical dermatology: a color guide to diagnosis and therapy . Mosby . St. Louis . 1990 . 27 . 0-8016-2465-7 . 2nd.
2. Side effects of topical steroids: A long overdue revisit. 2014. 4228634 . 25396122. 10.4103/2229-5178.142483. 5. 4. Indian Dermatol Online J. 416–425 . Coondoo . A . Phiske . M . Verma . S . Lahiri . K . free .
3. Harvey J, Lax SJ, Lowe A, Santer M, Lawton S, Langan SM, Roberts A, Stuart B, Williams HC, Thomas KS . October 2023 . The long-term safety of topical corticosteroids in atopic dermatitis: A systematic review . Skin Health and Disease . 3 . 5 . e268 . 10.1002/ski2.268 . 10549798 . 37799373.
4. Chu DK, Chu AW, Rayner DG, Guyatt GH, Yepes-Nuñez JJ, Gomez-Escobar L, Pérez-Herrera LC, Díaz Martinez JP, Brignardello-Petersen R, Sadeghirad B, Wong MM, Ceccacci R, Zhao IX, Basmaji J, MacDonald M, Chu X, Islam N, Gao Y, Izcovich A, Asiniwasis RN, Boguniewicz M, De Benedetto A, Capozza K, Chen L, Ellison K, Frazier WT, Greenhawt M, Huynh J, LeBovidge J, Lio PA, Martin SA, O'Brien M, Ong PY, Silverberg JI, Spergel JM, Smith Begolka W, Wang J, Wheeler KE, Gardner DD, Schneider L . December 2023 . Topical treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials . The Journal of Allergy and Clinical Immunology . 152 . 6 . 1493–1519 . 10.1016/j.jaci.2023.08.030 . 37678572 . 261610152.
5. Axon E, Chalmers JR, Santer M, Ridd MJ, Lawton S, Langan SM, Grindlay DJ, Muller I, Roberts A, Ahmed A, Williams HC, Thomas KS . July 2021 . Safety of topical corticosteroids in atopic eczema: an umbrella review . BMJ Open . 11 . 7 . e046476 . 10.1136/bmjopen-2020-046476 . 8264889 . 34233978.
6. Harvey J, Lax SJ, Lowe A, Santer M, Lawton S, Langan SM, Roberts A, Stuart B, Williams HC, Thomas KS . October 2023 . The long-term safety of topical corticosteroids in atopic dermatitis: A systematic review . Skin Health and Disease . 3 . 5 . e268 . 10.1002/ski2.268 . 10549798 . 37799373.
7. Chu DK, Chu AW, Rayner DG, Guyatt GH, Yepes-Nuñez JJ, Gomez-Escobar L, Pérez-Herrera LC, Díaz Martinez JP, Brignardello-Petersen R, Sadeghirad B, Wong MM, Ceccacci R, Zhao IX, Basmaji J, MacDonald M, Chu X, Islam N, Gao Y, Izcovich A, Asiniwasis RN, Boguniewicz M, De Benedetto A, Capozza K, Chen L, Ellison K, Frazier WT, Greenhawt M, Huynh J, LeBovidge J, Lio PA, Martin SA, O'Brien M, Ong PY, Silverberg JI, Spergel JM, Smith Begolka W, Wang J, Wheeler KE, Gardner DD, Schneider L . December 2023 . Topical treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials . The Journal of Allergy and Clinical Immunology . 152 . 6 . 1493–1519 . 10.1016/j.jaci.2023.08.030 . 37678572 . 261610152.
8. Axon E, Chalmers JR, Santer M, Ridd MJ, Lawton S, Langan SM, Grindlay DJ, Muller I, Roberts A, Ahmed A, Williams HC, Thomas KS . July 2021 . Safety of topical corticosteroids in atopic eczema: an umbrella review . BMJ Open . 11 . 7 . e046476 . 10.1136/bmjopen-2020-046476 . 8264889 . 34233978.
9. Lax SJ, Harvey J, Axon E, Howells L, Santer M, Ridd MJ, Lawton S, Langan S, Roberts A, Ahmed A, Muller I, Ming LC, Panda S, Chernyshov P, Carter B, Williams HC, Thomas KS, Chalmers JR . March 2022 . Strategies for using topical corticosteroids in children and adults with eczema . The Cochrane Database of Systematic Reviews . 2022 . 3 . CD013356 . 10.1002/14651858.CD013356.pub2 . 8916090 . 35275399 . Cochrane Skin Group.
10. Recommendations from New Zealand Dermatological Society Incorporated on corticosteroids
11. Book: Habif, Thomas P. . Clinical dermatology: a color guide to diagnosis and therapy . Mosby . St. Louis . 1990 . 27–30 . 0-8016-2465-7 . 2nd.
12. Adverse effects of topical corticosteroid use. DA. Fisher. 1022645. 7794369. 162. 2. 1995. West. J. Med.. 123–126.
13. 10.2165/00002018-200932060-00008 . van der Linden MW, Penning-van Beest FJ, Nijsten T, Herings RM . Topical corticosteroids and the risk of diabetes mellitus: a nested case-control study in the Netherlands . Drug Saf . 32 . 6 . 527–537 . 2009 . 19459719 . 38326748 .
14. Lebreton . O. . Weber . M. . 10.1016/j.revmed.2011.01.003 . Complications ophtalmologiques des corticoïdes systémiques . La Revue de Médecine Interne . 32 . 8 . 506–512 . 2011 . 21330017 .
15. Book: Wolverton, Stephen E. . Comprehensive Dermatologic Drug Therapy . W.B. Saunders Company . Philadelphia. 2001 . 562–563 . 0-7216-7728-2 .
16. Book: Wolverton, Stephen E. . Comprehensive Dermatologic Drug Therapy . W.B. Saunders Company . Philadelphia. 2001 . 562–563 . 0-7216-7728-2 .
17. Chi. Ching-Chi. Wang. Shu-Hui. Wojnarowska. Fenella. Kirtschig. Gudula. Davies. Emily. Bennett. Cathy. 2015-10-26. Safety of topical corticosteroids in pregnancy. Cochrane Database of Systematic Reviews. 2015. 10. CD007346. en. 10.1002/14651858.CD007346.pub3. 26497573. 8558096. 1465-1858. 2018-06-23. 2020-08-15. https://web.archive.org/web/20200815200300/https://www.cochrane.org/CD007346/SKIN_safety-topical-steroids-pregnancy. live.
18. Andersson . Niklas Worm . Skov . Lone . Andersen . Jon Trærup . 2021-07-01 . Evaluation of Topical Corticosteroid Use in Pregnancy and Risk of Newborns Being Small for Gestational Age and Having Low Birth Weight . JAMA Dermatology . en . 157 . 7 . 788 . 10.1001/jamadermatol.2021.1090 . 2168-6068 . 8100914 . 33950165.
19. Book: Habif, Thomas P. . Clinical dermatology: a color guide to diagnosis and therapy . Mosby . St. Louis . 1990 . Inside front cover . 0-8016-2465-7 . 2nd.
20. Web site: Topical steroids (corticosteroid creams) . DermNet NZ . 2008-12-05 . 2016-07-25 . https://web.archive.org/web/20160725120934/http://dermnetnz.org/treatments/topical-steroids.html . live .
21. Book: Wolverton, Stephen E. . Comprehensive Dermatologic Drug Therapy . W.B. Saunders Company . Philadelphia . 2001 . 562 . 0-7216-7728-2 .
22. Rattner H . The status of corticosteroid therapy in dermatology . Calif Med . 83 . 5. 331–335 . November 1955 . 13260925 . 1532588 .