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Topical Corticosteroids: Back to Basics

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Topical Corticosteroids: Back to Basics .............................. Best Practice Topical corticosteroids: back to basics Topical corticosteroids are among the most commonly required, should be limited to the lowest effective Nancy P Lee prescribed medications in the ambulatory setting.1 They strength.5 Edgar R Arriola a wide variety of der- Drug Information are the cornerstones of therapy for Center matoses, such as atopic dermatitis, contact dermatitis, pso- Vehicle Department of riasis, seborrheic dermatitis, and intertrigo.2'3 In addition, Pharmaceutical Services depends on the type oflesion and they may also serve as adjuvant or alternative therapy for The selection ofvehide UCLA Medical Center anatomic region that is affected. Most topical cortico- Los Angeles, CA 90095 various other inflammatory, hyperproliferative and pru- the steroids are available in many formulations, induding the clinical effects of to: ritic conditions. It is thought that ointment, cream, lotion, gel, solution, and aerosol. In ad- Correspondence anti- Dr Arriola topical corticosteroids are mediated by their dition to being a carrier for the active drug, the vehide inflammatory, vasoconstrictive, anti-proliferative, and im- [email protected] may function to hydrate the skin and augment drug pen- edu munosuppressive properties. etration. Ointments, which consist of oleaginous bases such as petrolatum, provide hydration to the stratum comeum by WHAT SHOULD BE CONSIDERED IN THE acting as an occlusive barrier. Penetration of the active SELECTION OF TOPICAL CORTICOSTEROIDS? agent is therefore enhanced, resulting in improved po- A myriad oftopical corticosteroid products is available for tency. Ointments are ideal for the management of dry, the management ofdermatoses. A basic understanding of scaly or lichenified lesions and on areas with thick skin, several key factors should help clinicians select appropriate such as the palms and soles. Emollient creams, which are preparations that maximize therapeutic efficacy yet mini- creams that contain an increased amount of petrolatum, mize the potential for adverse effects. are less greasy and may be more cosmetically appealing to In addition to evaluating the relative potency of the patients than ointments. In general, most creams, lotions active agent, clinicians should consider factors that modu- and gels are water based and do not significantly provide late the dinical efficacy of the selected agent, such as the hydration to the skin. These nonocclusive vehides are choice ofvehicle, the affected application site, and the use preferable for weeping lesions and for application on hairy of occlusive dressing. areas and flexures. (Note: some preparations are now for- mulated with an optimized vehide, resulting in equal po- tency for ointment, cream, and/or gel formulations.) Potency Since the introduction of topical hydrocortisone in the 1950s, various topical corticosteroids have been developed Application site to improve the degree of potency. In particular, chemical Absorption oftopical corticosteroids differs at various ana- alterations to the active moeity such as halogenation or tomic sites. Areas with thick stratum comeum, such as the esterification have produced intrinsically more potent soles of the feet or palms of the hand, allow for minimal agents. Topical corticosteroid preparations are categorized penetration. Consequently, high potency preparations according to their relative potency as determined by va- may be required on these areas to ensure a clinical re- socontrictive assays (Table 1). Keep in mind, however, the sponse. Areas such as the scrotum, parts ofthe face (eyelids vasoconstrictive activity may not always correlate with in particular), and intertriginous regions permit rapid and therapeutic efficacy.4 extensive drug penetration due to thinner stratum cor- The selection of potency should be based on the re- neum. These areas are therefore more susceptible to sponsiveness of the dermatologic condition. Highly re- adverse effects. The use of low potency preparations is sponsive dermatosis, such as intertriginous psoriasis or generally preferred in these areas, although recalcitrant atopic dermatitis, should be treated with weak corticoste- conditions (for example, discoid lupus erythematosus and roid preparations, whereas less responsive or recalcitrant lichen sclerosis) may require higher potency preparations.4 conditions (for example, palmoplantar or nail psoriasis, Another consideration is the extent of skin involve- lupus erythematosus) often require higher potency ment requiring topical corticosteroid therapy. Because of agents.3 When a high potency agent is selected initially to increased risk ofsystemic absorption, low to medium po- control and arrest the dermatosis, maintenance therapy, if tency preparations are preferable when treating large sur- Volume 171 November/December 1999 wlm 351 ................................. Best Practice Table s Group I (Most Potent) Betamethasone dipropionate Diprolene', Diprolene0 AF 0.05% Cream, ointment, or gel (optimized vehicle) Clobetasol propionate Temovate0 o.os% Cream or ointment Diflorasone diacetate Psorcons o.o0% Ointment (optimized vehicle) Group 11 Amcinonide Cyclocort0 0.1% Ointment Betamethasone dipropionate Diprosones o.o05% Ointment Desoximetasone Topicorts 0.25% Cream or ointment Desoximetasone Topicort' o.os% Gel Diflorasone diacetate Florone', Maxiflor o.os% Ointment Fluocinonide Lidex' o.os% Cream, ointment, or gel Halcinonide Halogr O.I% Cream .................................................................................................................................................................................................................. Group III Betamethasone diproprionate Diprosone' o.o0% Cream Betamethasone valerate Valisone' o.1% Ointment Diftorasone diacetate FloroneO, Maxiftors o.os% Cream Mometasone furoate Elocon' o.i% Ointment Triamcinolone acetonide Aristocort' o.s% Cream .................................................................................................................................................................................................................. Group IV Desolxmetasone Topicort' LP o.o5% Cream Fluocinolone acetonide Synalar" HP 0.2% Cream Fluocinolone acetonide Synalar' 0.025% Ointment Flurandrenolide Cordran' 0.05% Ointment Triamcinotone acetonide Aristocort*, Kenalog' o.i% Ointment .................................................................................................................................................................................................................. Group V Betametasone dipropinate Diprosone' o.o0% Lotion Betametasone valerate Valisone's o.1% Cream, lotion Fluocinolone acetonide Synalar' 0.025% Cream Flurandrenolide Cordran' o.os% Cream Hydrocortisone butyrate Locoid' 0.1% Cream Hydrocortisone valerate Westcort' 0.2% Cream Prednicarbate Dermatop' o.i% Cream Triamcinolone acetonide Kenalog' 0.1% Cream, lotion .................................................................................................................................................................................................................. Group VI Alclometasone diproprionate Aclovate' o.os% Cream, ointment Desonide Tridesilon' o.os% Cream Fluocinolone acetonide Synalar' o.oi% Solution Note: Group I represents the super-potent category; potency descends with each group; Group VIl consist ofweak topical corticosteroids such as hydrocortisone, dexamethasone, prednisolone, and methylprednisolone. face areas.4 The integrity ofthe epidermal area should also daily applications have been recommended.5'7 Recent un- be evaluated when selecting a preparation to avoid exces- derstanding ofdrug penetration and deposition, however, sive percutaneous corticosteroid absorption. suggests less frequent application may be more appropriate owing to the depot effect of the skin. Less frequent appli- Occlusive dressings cation also offers the advantages of reducing the develop- The use of occlusive dressing to enhance drug potency is ment ofside effects and tachyphylaxis, improving patient less common because of the availability of super potent compliance, and reducing the cost of therapy.7 topical corticosteroids. Application of occlusive dressings, General guidelines developed by American Academy however, such as plastic wraps and hydrocolloid dressings, ofDermatology advise once or twice daily applications for remains an effective method when treating localized, re- most topical corticosteroid preparations. Skin with thick calcitrant conditions. The permeability of the drug under stratum corneum from which the medication is easily re- ocdusive dressing may be increased up to 10-fold.6 moved may require more frequent application; intermit- tent and intermittent scheduling (for example, every other WHAT IS THE OPTIMAL FREQUENCY day, weekends only) may be effective for chronic condi- OF APPLICATION? tions requiring maintenance therapy.4 Daily application The frequency of application varies with the preparation of nonmedicated emollient creams or ointments may be selected and the condition treated. Traditionally, multiple substituted during the drug-free intervals.6 352 wjm Volume 171 November/December 1999 Best Practice1 WHAT ARE THE POTENTIAL ADVERSE EFFECTS WHAT SPECIAL PRECAUTIONS SHOULD OF TOPICAL CORTICOSTEROID THERAPY? BE CONSIDERED IN PEDIATRIC AND Systemic adverse effects GERIATRIC PATIENTS? A major concern associated with topical corticosteroid Pediatric patients, in particularly infants,
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