Supplement to the December 2009 &AGING Series: Relevance of Low-Potency Topical Steroids in Dermatology The Role of Low-Potency Topical Steroids in Day-to-Day Practice Supplement supported by ® HMP COMMUNICATIONS 83 GENERAL WARREN BLVD, SUITE 100, MALVERN, PA 19355 • (800) 237-7285 • (610) 560-0500 • FAX (610) 560-0501 EDITORIAL STAFF DESIGN AND PRODUCTION BUSINESS STAFF EXECUTIVE EDITOR STEFANIE TULEYA CREATIVE DIRECTOR VIC GEANOPULOS VICE PRESIDENT/GROUP PUBLISHER WILLIAM W. HARLEY MANAGING EDITOR ELLEN MEYER ART DIRECTOR KAREN COPESTAKES NATIONAL ACCOUNT MANAGER ROBYN TANZER SPECIAL PROJECTS EDITOR STEPHANIE WASEK PRODUCTION MANAGER TRISH MORRIS 2009-560-018-A The Role of Low-Potency Topical Steroids in Day-to-Day Practice Johnnie M. Woodson, MD Assistant Clinical Professor of Dermatology University of Nevada School of Medicine Henderson, NV opical corticosteroids are one of the oldest treat - matitis, psoriasis, pityriasis rosea, nummular dermatitis, atopic ments for a variety of dermatologic conditions. dermatitis, dyshidrotic eczema, diaper dermatitis, erythro - TThey are used to treat conditions such as psoriasis, derma, lichen simplex chronicus, lichen planus, alopecia vitiligo, eczema, atopic dermatitis, phimosis, acute radia - areata, pruritus, vitiligo, acne keloidalis nuchae and granuloma tion dermatitis and lichen sclerosus. 1 Topical corticos - annulare. Ference and Last note that the keys to successful teroids are also used to treat melasma, chronic idiopathic treatment “[depend] on an accurate diagnosis and consider - urticaria and alopecia areata, but evidence of efficacy ation of the steroid's delivery vehicle, potency, frequency of with these conditions is limited. 1 application, duration of treatment and side effects.” 1 Further, their long history of safety and effectiveness To describe the effect intensity of topical corticos - for certain conditions means they remain one of the most teroids, potency is the term used. To measure the anti-in - useful and widely prescribed treatments in day-to-day flammatory and the antiproliferative properties, certain dermatologic practice — nearly 1.7 million prescriptions assays are utilized. A very commonly used assay is the are dispensed each year for treatment of dermatological vasoconstrictor assay and this is usually used by re - conditions (see Table 1 ). 2 searchers because it correlates well with clinical efficacy. These benefits — safety, use across a wide spectrum of The test is subjective, which is one of the disadvantages dermatoses — make topical corticosteroids a desirable of using this assay. Clinical potency of topical corticos - tool for any dermatologist. This article will specifically teroids usually depends on several factors, including the explore the role and use of topical low-potency steroids structure of the molecule, the area of the skin it is applied (LPS) in day-to-day practice. to and the vehicle it is used in. Topical corticosteroids can have a number of undesir - LPS AS DAILY TREATMENT able side effects, including atrophic changes, more fragile Some of the selected indications of topical corticosteroids skin, more easily bruised skin, increased risk for infection, in dermatologic uses are for the treatment of seborrheic der - masked infection, secondary infection, contact dermatitis, TABLE 1. DERMATOLOGY: LOW-POTENCY TOPICAL STEROID PRESCRIPTIONS OVER 1 YEAR VEHICLE PRESCRIPTIONS FILLED Ointment 413,759 Cream 727,030 Liquid 545,750 Combination form 2,923 TOTAL 1,689,462 Note: Wolters Kluwer data gathered over 12 months in 2008–09. 2 Supplement to Skin & Aging N December 2009 3 LOW-DOSE STEROIDS FIGURE 1. While higher-potency topical steroid formula - FIGURE 2. Successful treatments target the root cause to tions may be used short-term in particularly acute cases, relieve symptoms and improve quality-of-life factors such as avoid them for use longer than 3 weeks and on more sensi - physiological distress and embarrassment with appearance tive areas of the body, such as the face, groin and axilla. of skin and/or constant scratching. delayed wound healing, hyperpigmentation, hypopig - ment before the desired response is achieved, while a se - mentation and photosensitization. 1 vere case may not respond, or may respond very little, Because of this, dermatologists want to use the lowest- even after long-term use. 5 potency steroid that will effectively alleviate symptoms of Strategies in such acute cases include varying the dose dermatoses. 3 While higher-potency formulations may be (e.g., using stronger topical steroids on weekends and used short-term in particularly acute cases, they are to be weaker formulations on weekdays); stepping up the dose avoided for long-term use — longer than 2 weeks — and (i.e., starting weaker and moving to a stronger formula - on more sensitive areas of the body, such as the face, groin tion); or stepping down the dose (ie, starting more potent and axilla. 1,3,4 Milder formulations are therefore used when and gradually moving to a less-potent formulation). 5,6 day-to-day maintenance or topical use on sensitive skin, Trial and error is often necessary in order to tailor the thinner skin or children’s skin is called for. 1,4 dosage and schedule to each patient. 1 This doesn’t mean a dermatologist should use a topical When prescribing, dermatologists need to take into ac - count the following safety considera - tions: body surface area, duration and A formulation that combines hydrocortisone acetate and individual patient needs. Considering these factors is important in order to pramoxine hydrochloride results in the ability to relieve avoid potential side effects. In fact, se - pruritus and inflammation associated with many dermatoses. vere side effects are rare with topical LPS, even when they are used over many years. 4 steroid potency that is too low to treat a given patient’s symptoms. Rather, the idea is to match lowest strength and MECHANISMS OF ACTION smallest quantity of corticosteroid to properly address the Topical corticosteroids have anti-inflammatory and an - severity of the dermatosis the patient has presented with. 5 tiproliferative effects. The immediate anti-inflammatory For example, mild eczema can be treated with twice- effects are that they stabilize cell membranes and prevent a-day topical LPS, often completely clearing the outbreak the release of lysosomal contents; they reduce vascular within 1 or 2 weeks. 1,5 Moderate eczema may require a smooth muscle and sensitivity to histamine; they reduce more potent formulation and/or longer duration of treat - mast cell sensitization induced by immunoglobulin E; and 4 December 2009 N Supplement to Skin & Aging TABLE 2. EXAMPLES OF COMMON CORTICOSTEROID-RESPONSIVE DERMATOSES • Allergic dermatitis • Poison plant eruptions (poisons ivy, oak and sumac) • Atopic dermatitis/eczema • Post-chicken pox • Contact dermatitis • Post-scabies (allergic and irritant-specific) • Pruritus ani • Drug eruptions • Pruritus (specific and non-specific) • Insect bites • Sunburn • Lichen sclerosus/planus/striatus • Urticaria • Neurodermatitis (lichen simplex chronicus) TABLE 3. ONSET OF RELIEF TIME (RELATING TO ITCH-SCRATCH CYCLE) PRODUCT ONSET OF ACTION PEAK EFFECT DURATION OF ACTION Pramoxine hydrochloride 2 to 5 minutes 3 to 5 minutes Several days Hydrocortisone acetate slow n/a long Note: Adapted from University of Maryland Medical Center Complimentary and Alternative Medicine Index. 14,15 they inhibit the release of histamine and other mast cell BENEFITS OF PRAMOXINE mediators. Topical corticosteroids can also decrease the Because of its anesthetic properties, the addition of natural cell-killing activity and decrease response to lym - pramoxine may be helpful in ameliorating itch sensation. 7 phocyte reaction. Pramoxine hydrochloride is widely used as a surface In my experience, topical glucocorticosteroids also anesthetic because it combines effectiveness with low sys - have delayed anti-inflammatory effects, such as preventing temic toxicity. 8 According to a 1954 study by Peal and formation of potent inflammatory mediators, decreasing Karp, it exhibits low potential for sensitization and irri - vascular permeability, and producing the induction of tation. 9 Subsequent study has confirmed the safety profile anti-inflammatory proteins. Glucocorticosteroids act on and wide-ranging effectiveness of pramoxine. different cell types, including polymorphonuclear leuko - A double-blind study of 15 patients examined how the cytes (PMNs) and lymphocytes. They decrease PMN application of pramoxine lotion and pramoxine vehicle movement to inflammation sites, reduce PMN numbers affected perception of histamine-induced pruritus and at inflammation sites, and decrease their ability to attach the warmth and pain thresholds that result from this pru - to the inside of vascular channels called the endothelium. ritus. The authors found that, while cold and heat pain Glucocorticosteroids can also decrease the production of thresholds were unaffected, warmth sensation threshold certain interleukins as well as tumor necrosis factor. increased significantly — by 0.4˚ C — after histamine- I’ve also found that topical glucocorticosteroids exhibit induced itch. 10 Pramoxine lotion was found to signifi - antiproliferative effects that can affect each of the skin’s cantly reduce the cold pain threshold, while pramoxine layers. For example, in the epidermis, they can decrease vehicle significantly decreased warmth sensation; the re - the thickness of the stratum corneum, affect the ker