The role of corticosteroids in dermatology

Introduction

  • Dermatology is one of the few disciplines in which we are able to apply therapy directly to the target site.
  • The concentration, the vehicle and the frequency of application can all be altered according to the response, which can easily be monitored.
  • Corticosteroids have an important role because of their anti- inflammatory and immunosuppressive effects and also their anti-proliferative effects on keratinocytes.
  • They can suppress collagen synthesis by fibroblasts, but this may lead to adverse effects. Conversely, this effect can help in the treatment of keloid scars.

Corticosteroids can also be given orally, parenterally or by injection into the lesion.

Topical corticosteroids

The vasoconstrictor assay is the primary method of classifying the potency of topical steroids. This correlates with clinical efficacy.

The efficacy and possible adverse effects depend on:

– steroid type and the vehicle

– application method – frequency, duration and use under occlusion

– nature and extent of the skin disease

– patient factors – age, site of the disease

All these factors have to be taken into account to obtain the maximum benefit with the minimum adverse effects.

Skin disease

  • In general, acute inflammatory eruptions respond well to mild/moderate strength topical steroids (Class I and II).
  • Chronic, thickened or hyperkeratotic dermatoses may require potent or very potent steroids (Class III and IV).

Vehicle

For a given strength of the same steroid, ointments are more potent than creams. The occlusive nature of ointment enhances steroid penetration. Ointment is often used for dry, fissured and lichenified skin disease because of its moisturising effect.

Creams (oil in water emulsions) may be drying and thus more suitable for acute and subacute weeping lesions. They are the most suitable vehicle for the moist and intertriginous (flexural) areas. Creams require the addition of emulsifiers and preservatives that have the potential to sensitise and cause allergic reactions.

For the scalp, steroids are often delivered in a lotion or gel. These vehicles lack the moisturising benefit of either creams or ointments. Propylene glycol can act as a penetration enhancer. By using it in a vehicle, the delivery of the topical steroid can be increased.

A classification of the potency of commonly used topical corticosteroid preparations
Class I – mild
hydrocortisone0.5 – 1.0%
hydrocortisone acetate0.5 – 1.0%
Class II – moderate
aclomethasone dipropionate0.05%
betamethasone valerate0.02%
betamethasone valerate0.05%
triamcinolone acetonide0.02%
triamcinolone acetonide0.05%
Class III – potent
betamethasone dipropionate0.05%
betamethasone valerate0.1%
methylprednisolone aceponate0.1%
mometasone furoate0.1%
Class IV – very potent
betamethasone dipropionate0.05% in an optimised vehicle
halcinonide0.1%
A guideline of cutaneous diseases for which corticosteroids are used, and the likely clinical response
Most responsiveLess responsiveLeast responsive
Acute inflammatory disease including:Psoriasis – plaquePalmoplantar psoriasis
– allergic contact dermatitisSeborrhoeic dermatitisDiscoid lupus erythematosus
– atopic eczemaLichen simplex chronicusChronic hypertrophic lichen planus
– asteatotic eczemaLichen planusGranuloma annulare
– discoid eczemaSubacute cutaneous lupus erythematosusKeloid scars
– napkin dermatitisPapular urticaria (insect bite reactions)

Occlusion

  • The efficacy of steroids can be increased by application under occlusion.
  • This increases hydration of the skin and enhances penetration.
  • However, there is an increased risk of adverse effects if the use of steroid under occlusion is prolonged.
  • The occluding materials can include polythene gloves, plastic film (such as ‘Gladwrap’) and bio-occlusive dressings e.g. hydrocolloid.

Region or sites

  • The thickness of the stratum corneum,
  • local occlusive factors,
  • warmth and moisture are among the factors that can increase corticosteroid penetration and also the risk of adverse effects.

As a rule, Class I steroids are preferred for the face and flexures. If a stronger corticosteroid is required, short-term (1-2 weeks) use is recommended.

In contrast, palms and soles tend to require Class III or IV steroids as there is a thick stratum corneum and frequent accidental removal of the steroid may occur.

Age

Premature babies and the elderly have relatively thin skin so steroid penetration is enhanced. The lower potency steroids are used first in this group. Particular care should be given when steroids are used in the nappy area.

If treatment involves application to a large proportion of the body surface area, low- to medium-strength steroids are preferred because of the risk of extensive absorption.

guidelines

1. Topical steroids should be stopped when the skin disease has resolved. They are not used for prevention of disease.

2. If possible, intermittent therapy is preferred to continuous application for long-term use. This is to reduce both tachyphylaxis and the risk of adverse effects.

3. Prolonged use should be avoided, where possible, on the face and the flexures.

4. Some people benefit from using a more potent steroid first and then changing to a lower potency as the condition improves.

Adverse effects

In general, the greater the potency, the greater the risk of adverse effects.

Skin atrophy, stellate scar and striae
Purpura and haemorrhage
Telangiectasia
Periocular, perioral dermatitis of the face
Folliculitis
Acneiform eruptions
Masking and aggravating fungal infections
Delayed wound healing
Hypertrichosis
Secondary infection and aggravating existing bacterial infections

Contact dermatitis
– preservatives
– other ingredients in vehicles
– corticosteroid itself

Systemic adverse effects may occur with the use of topical steroids. The risk factors include use in infants and children, prolonged and extensive use, use of high-potency steroids, use over large areas and use under occlusion. The adverse effects include the standard ones of adrenal suppression, growth retardation, Cushing’s syndrome and hypertension. Cataracts and glaucoma have been reported with periorbital use.

Intralesional therapy

The steroid is injected directly into the lesion. The common indications include recalcitrant lesions of nodular prurigo, keloid scars, acne cysts, discoid lupus erythematosus, hypertrophic lichen planus, alopecia areata and granuloma annulare.

Triamcinolone acetonide is most often used.

  • It can be diluted with normal saline or lignocaine and is delivered in volumes of 1-2 mL.
  • The concentration used depends on the pathology and skin site.
  • Generally, one commences with a concentration of 5 mg/mL working up to the full concentration of 40 mg/mL, if necessary, when there is no response. If required, the injection can be repeated every 4-6 weeks.

Systemic corticosteroids

Steroids are required systemically for:

– acute and chronic disabling bullous disorders including pemphigus vulgaris, bullous pemphigoid, pemphigoid gestationalis

– connective tissue diseases – systemic lupus erythematosus, dermatomyositis, Wegener’s granulomatosis, relapsing polychondritis

– acute steroid sensitive disorders, e.g. severe acute allergic contact dermatitis where the allergen is known and can be avoided to prevent relapse on cessation of steroids

– severe, widespread, inflammatory atopic eczema where acute control is required (care is necessary on cessation of the oral steroids to prevent a widespread severe relapse)

– others – severe lichen planus, urticaria, pyoderma gangrenosum, Sweet’s disease, Behcet’s and severe vasculitis

Oral steroids are perfectly satisfactory in the majority of dermatology patients who are rarely ill enough to require either intramuscular or intravenous administration.

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