Choosing Topical Corticosteroids JONATHAN D. FERENCE, PharmD, Nesbitt College of Pharmacy and Nursing, Wilkes University, Wilkes-Barre, Pennsylvania ALLEN R. LAST, MD, MPH, Racine Family Medicine Residency Program, Medical College of Wisconsin, Racine, Wisconsin Topical corticosteroids are one of the oldest and most useful treatments for dermatologic conditions. There are many topical steroids available, and they differ in potency and formulation. Successful treatment depends on an accurate diagnosis and consideration of the steroid’s delivery vehicle, potency, frequency of application, duration of treatment, and side effects. Although use of topical steroids is common, evidence of effectiveness exists only for select condi- tions, such as psoriasis, vitiligo, eczema, atopic dermatitis, phimosis, acute radiation dermatitis, and lichen sclero- sus. Evidence is limited for use in melasma, chronic idiopathic urticaria, and alopecia areata. (Am Fam Physician. 2009;79(2):135-140. Copyright © 2009 American Academy of Family Physicians.) opical steroids are available in a Indications variety of potencies and prepara- An accurate diagnosis is essential when tions. Physicians should become selecting a steroid. A skin scraping and familiar with one or two agents in potassium hydroxide test can clarify whether T each category of potency to safely and effec- a steroid or an antifungal is an appropriate tively treat steroid-responsive skin condi- choice, because steroids can exacerbate a tions. When prescribing topical steroids, fungal infection. Topical corticosteroids are it is important to consider the diagnosis effective for conditions that are character- as well as steroid potency, delivery vehicle, ized by hyperproliferation, inflammation, frequency of administration, duration of and immunologic involvement. They can treatment, and side effects. The useful- also provide symptomatic relief for burning ness and side effects of topical steroids are and pruritic lesions. a direct result of their anti-inflammatory Many skin conditions are treated with properties, although no single agent has topical steroids (Table 1), but evidence of been proven to have the best benefit-to-risk effectiveness has been established only for ratio. a small number of conditions. For example, high- or ultra-high-potency topical steroids, alone or in combination with other topical Table 1. Conditions Treatable with Topical Steroids treatments, are the mainstay of therapy for psoriasis.1 They are also effective for treating High-potency steroids (groups I to III) Atopic dermatitis vitiligo involving a limited area of a patient’s Alopecia areata Lichen sclerosus (vulva) skin,2,3 lichen sclerosus,4 bullous pemphi- Atopic dermatitis (resistant) Nummular eczema goid, and pemphigus foliaceus.5,6 Alopecia Discoid lupus Scabies (after scabicide) areata, which is usually self-limited, may Hyperkeratotic eczema Seborrheic dermatitis respond to ultra-high-potency topical corti- Lichen planus Severe dermatitis costeroids, but randomized controlled trials Lichen sclerosus (skin) Severe intertrigo (short-term) have yielded conflicting results.7,8 Lichen simplex chronicus Stasis dermatitis Medium- to high-potency topical cortico- Nummular eczema Low-potency steroids steroids are effective for atopic dermatitis and Poison ivy (severe) (groups VI and VII) 9,10 Psoriasis Dermatitis (diaper) eczema in adults and children, as well as 11,12 Severe hand eczema Dermatitis (eyelids) for phimosis (i.e., foreskin that cannot be 13,14 Medium-potency steroids Dermatitis (face) retracted) and acute radiation dermatitis. (groups IV and V) Intertrigo Topical corticosteroids may be effective for Anal inflammation (severe) Perianal inflammation other conditions, but the data to support their Asteatotic eczema use are from small, low-level, or uncorrobo- rated studies. Melasma,15 chronic idiopathic January 15, 2009 ◆ Volume 79, Number 2 www.aafp.org/afp American Family Physician 135 Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2009 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Topical steroids can be used to treat psoriasis, vitiligo, lichen sclerosus, atopic dermatitis, eczema, and C 1, 2, 4, 9-13 acute radiation dermatitis. Ultra-high-potency topical steroids should not be used continuously for longer than three weeks. C 21 Low- to high-potency topical steroids should not be used continuously for longer than three months to C 21 avoid side effects. Combinations of topical steroids and antifungal agents generally should be avoided to reduce the risk C 31 of tinea infections. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp. org/afpsort.xml. urticaria,16 infantile acropustulosis,17 prepubertal labial Because hydration generally promotes steroid pen- adhesions,18 and transdermal testosterone-patch–induced etration, applying a topical steroid after a shower or skin irritation19 fall into this category. bath improves effectiveness.20 Occlusion increases ste- roid penetration and can be used in combination with Steroid Vehicles all vehicles. Simple plastic dressings (e.g., plastic wrap) Steroids may differ in potency based on the vehicle in result in a several-fold increase in steroid penetration which they are formulated. Some vehicles should be used compared with dry skin.21 Occlusive dressings are often only on certain parts of the body. Ointments provide used overnight and should not be applied to the face or more lubrication and occlusion than other preparations, intertriginous areas. Irritation, folliculitis, and infec- and are the most useful for treating dry or thick, hyper- tion can develop rapidly from occlusive dressings, and keratotic lesions. Their occlusive nature also improves patients should be counseled to monitor the treatment steroid absorption. Ointments should not be used on site closely. Flurandrenolide (Cordran) 4 mcg per m2 hairy areas, and may cause maceration and folliculitis impregnated dressing is formulated to provide occlu- if used on intertriginous areas (e.g., groin, gluteal cleft, sion. It is beneficial for treating limited areas of inflam- axilla). Their greasy nature may result in poor patient mation in otherwise difficult-to-treat locations, such as satisfaction and compliance. fingertips. Creams are mixes of water suspended in oil. They have good lubricating qualities, and their ability to van- Potency ish into the skin makes them cosmetically appealing. The preferred way to determine topical steroid potency Creams are generally less potent than ointments of the is the vasoconstrictor assay, which classifies steroids same medication, and they often contain preservatives, based on the extent to which the agent causes cutaneous which can cause irritation, stinging, and allergic reac- vasoconstriction (“blanching effect”) in normal, healthy tion. Acute exudative inflammation responds well to persons. This is a useful but imperfect method for pre- creams because of their drying effects. Creams are also dicting the clinical effectiveness of steroids.21 The anti- useful in intertriginous areas where ointments may not inflammatory potency of some steroids may vary among be used. However, creams do not provide the occlusive patients, depending on the frequency of administration, effects that ointments provide. the duration of treatment, and where on the body they Lotions and gels are the least greasy and occlusive are used.22,23 A ranking system that compares clinical of all topical steroid vehicles. Lotions contain alco- outcomes or an effectiveness-to-safety ratio may be of hol, which has a drying effect on an oozing lesion. greater benefit, but does not currently exist. Lotions are useful for hairy areas because they pene- There are seven groups of topical steroid potency, trate easily and leave little residue. Gels have a jelly-like ranging from ultra high potency (group I) to low potency consistency and are beneficial for exudative inflamma- (group VII). Table 2 provides a list of topical steroids and tion, such as poison ivy. Gels dry quickly and can be available preparations listed by group, formulation, and applied on the scalp or other hairy areas and do not generic availability.24 Brand name agents may be more cause matting. expensive, which may reduce patient compliance. This Foams, mousses, and shampoos are also effective vehi- should be considered when choosing steroid agents. Phy- cles for delivering steroids to the scalp. They are easily sicians should also be aware that some generic formula- applied and spread readily, particularly in hairy areas. tions have been shown to be less or more potent than Foams are usually more expensive. their brand-name equivalent.25 136 American Family Physician www.aafp.org/afp Volume 79, Number 2 ◆ January 15, 2009 Table 2. Potency Ratings of Topical Corticosteroids Medication Potency (group) Generic Brand Dosage vehicle Available sizes Ultra high (I) Augmented betamethasone Diprolene* G,† O 15, 45, 50 g dipropionate 0.05% Clobetasol propionate 0.05% Clobex L, Sh 59, 118 mL (L);