Topical steroids are the topical forms of corticosteroids. Topical steroids are the most commonly prescribed topical medications for the treatment of rash, eczema, and dermatitis. Topical steroids have anti-inflammatory properties, and are classified based on their vasoconstriction 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.
Over the past decade, much awareness has been brought to the side effects and damage that long term topical steroid use can bring, particularly in cases where it used for the treatment of eczema.[2][3]
Contents
- 1 Medical uses
- 2 Adverse effects
- 3 Classification systems
- 3.1 USA system
- 3.1.1 Group I
- 3.1.2 Group II
- 3.1.3 Group III
- 3.1.4 Group IV
- 3.1.5 Group V
- 3.1.6 Group VI
- 3.1.7 Group VII
- 3.2 Other countries
- 3.2.1 Class IV
- 3.2.2 Class III
- 3.2.3 Class II
- 3.2.4 Class I
- 3.3 Japan classification
- 3.4 Allergy associations
- 3.4.1 Group A
- 3.4.2 Group B
- 3.4.3 Group C
- 3.4.4 Group D
- 4 History
- 5 See also
- 6 References
Medical uses
Weaker topical steroids are utilized for thin-skinned and sensitive areas, especially areas under occlusion, such as the armpit, groin, buttock crease, 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]
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.[4] 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.[5]
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
- Lymphoma (cancer)[6]
- Hypothalamic pituitary adrenal axis (HPA) suppression[7]
- Cushing's syndrome
- Diabetes mellitus[8]
- Osteoporosis
- Topical steroid addiction: Topical steroid addiction (TSA) has been reported in long-term users of topical steroids (users who applied topical steroids to their skin over a period of weeks, months, or years).[9][10] TSA is characterised by uncontrollable, spreading dermatitis and worsening skin inflammation which requires a stronger topical steroid to get the same result as the first prescription. When topical steroid medication is stopped, the skin experiences redness, burning, itching, hot skin, swelling, and/or oozing for a length of time. This is also called 'red skin syndrome' or 'topical steroid withdrawal'(TSW). After the withdrawal period is over the atopic dermatitis can cease or is less severe than it was before.[11]
- 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 intra-ocular pressure (IOP) and increase the risk of glaucoma, cataract, retinopathy as well as systemic adverse effects.[12]
- Tachyphylaxis: The acute development of tolerance to the action of a drug after repeated doses.[13] 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.[14]
Classification systems
See also: ATC code D07
USA system
The USA system utilizes 7 classes, which are classified by their ability to constrict capillaries. Class I is the strongest, or superpotent. Class VII is the weakest and mildest.[15]
Group 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)
Group II
- Fluocinonide 0.05% (Lidex)
- Halcinonide 0.05% (Halog)
- Amcinonide 0.05% (Cyclocort)
- Desoximetasone 0.25% (Topicort)
Group III
- Triamcinolone acetonide 0.5% (Kenalog, Aristocort cream)
- Mometasone furoate 0.1% (Elocon ointment)
- Fluticasone propionate 0.005% (Cutivate)
- Betamethasone dipropionate 0.05% (Diprosone)
- Halometasone 0.05%
Group 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)
Group 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)
Group 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)
Group 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)
Other countries
Most other countries, such as the United Kingdom, Germany, the Netherlands, New Zealand, recognize only 4 classes.[16] In New Zealand I is the strongest, while in Continental Europe, class IV is regarded as the strongest.
Class IV
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
Potent (50-100 times as potent as hydrocortisone)
- Betamethasone valerate (Beta Cream/Ointment/Scalp Application, Betnovate Lotion/C Cream/C Ointment, Daivobet 50/500 Ointment, Fucicort)
- Betamethasone dipropionate (Diprosone Cream/Ointment, Diprovate Cream)
- 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
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
Mild
- Hydrocortisone 0.5-2.5% (DermAid Cream/Soft Cream, DP Lotion-HC 1%, Skincalm, Lemnis Fatty Cream HC, Pimafucort Cream/Ointment)
Japan classification
Japan rates topical steroids from 1 to 5, with 1 being strongest.
Allergy associations
The highlighted steroids are often used in the screening of allergies to topical steroid and systemic steroids.[17] 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.[18]
See also
- Topical
- Glucocorticoid
- Corticosteroid
- Retrometabolic drug design
References
- ^ a b Habif, Thomas P. (1990). Clinical dermatology: a color guide to diagnosis and therapy (2nd ed.). St. Louis: Mosby. p. 27. ISBN 0-8016-2465-7.
- ^ "Side effects of topical steroids: A long overdue revisit". 2014. Retrieved June 11, 2015.
- ^ "Barrier repair creams target the downside of topical corticosteroid treatment". Dermatology Times. March 1, 2012. Retrieved June 11, 2015.
- ^ Recommendations from New Zealand Dermatological Society Incorporated on corticosteroids
- ^ Habif, Thomas P. (1990). Clinical dermatology: a color guide to diagnosis and therapy (2nd ed.). St. Louis: Mosby. pp. 27–30. ISBN 0-8016-2465-7.
- ^ "Patients with atopic dermatitis may have slightly increased lymphoma risk". May 7, 2015.
- ^ Fisher, DA. "Adverse effects of topical corticosteroid use".
- ^ van der Linden MW, Penning-van Beest FJ, Nijsten T, Herings RM (2009). "Topical corticosteroids and the risk of diabetes mellitus: a nested case-control study in the Netherlands". Drug Saf 32 (6): 527–37. doi:10.2165/00002018-200932060-00008. PMID 19459719.
- ^ Nnoruka, Edith; Daramola, Olaniyi; Ike, Samuel (2007). "Misuse and abuse of topical steroids: implications.". Expert Review of Dermatology 2 (1): 31–40. doi:10.1586/17469872.2.1.31. Retrieved 2014-12-18.
- ^ Sanjay, Rathi; D'Souza, Paschal (2012). "Rational and ethical use of topical corticosteroids based on safety and efficacy.". Indian Journal of Dermatology 57 (4): 251–259. doi:10.4103/0019-5154.97655.
- ^ Fukaya, M; Sato, K; Sato, M; Kimata, H; Fujisawa, S; Dozono, H; Yoshizawa, J; Minaguchi, S (2014). "Topical steroid addiction in atopic dermatitis.". Drug, healthcare and patient safety 6: 131–8. doi:10.2147/dhps.s69201. PMID 25378953.
- ^ Lebreton, O.; Weber, M. (2011). "Complications ophtalmologiques des corticoïdes systémiques". La Revue de Médecine Interne 32 (8): 506–512. doi:10.1016/j.revmed.2011.01.003. PMID 21330017.
- ^ Wolverton, Stephen E. (2001). Comprehensive Dermatologic Drug Therapy. Philadelphia, PA: W.B. Saunders Company. pp. 562–3. ISBN 0-7216-7728-2.
- ^ Wolverton, Stephen E. (2001). Comprehensive Dermatologic Drug Therapy. Philadelphia, PA: W.B. Saunders Company. p. 563. ISBN 0-7216-7728-2.
- ^ Habif, Thomas P. (1990). Clinical dermatology: a color guide to diagnosis and therapy (2nd ed.). St. Louis: Mosby. p. Inside front cover. ISBN 0-8016-2465-7.
- ^ http://dermnetnz.org/treatments/topical-steroids.html
- ^ Wolverton, Stephen E. (2001). Comprehensive Dermatologic Drug Therapy. Philadelphia, PA: W.B. Saunders Company. p. 562. ISBN 0-7216-7728-2.
- ^ Rattner H (November 1955). "THE STATUS OF CORTICOSTEROID THERAPY IN DERMATOLOGY". Calif Med 83 (5): 331–5. PMC 1532588. PMID 13260925.
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Glucocorticoids and antiglucocorticoids (H02)
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| Agonists |
| Pregnene |
|
|
| Pregnenedione |
- Hydrocortisone (cortisol)# (Hydrocortisone aceponate
- Hydrocortisone buteprate
- Hydrocortisone butyrate)
- Budesonide
- Ciclesonide
- Deflazacort
- Medrysone
- Tixocortol
- Halogenated at 6: Cloprednol
- Halogenated, with FG at 16: Halcinonide
|
|
| Pregnadiene |
- Rimexolone
- Halogenated, with FG at 16: Flunisolide
- Triamcinolone
- Amcinonide
- Fluocinolone acetonide (Fluocinonide)
|
|
| Pregnadienediol |
- Prednisone (Meprednisone)
- Halogenated at 9: Fluorometholone
- Halogenated, with FG at 16: Fluocortolone (Clocortolone
- Diflucortolone
- Fluocortin)
- Desoximetasone
|
|
| Pregnadienetriol |
- Prednisolone# (Methylprednisolone
- Methylprednisolone aceponate
- Prednicarbate
- Prednylidene)
- Desonide
- Halogenated: Fluprednisolone (Difluprednate
- Fluperolone)
- Halogenated, with FG at 16: Dexamethasone#
- Betamethasone (Clobetasol
- Clobetasone
- Diflorasone
- Halometasone
- Ulobetasol)
- Beclometasone
- Paramethasone
- Alclometasone
- Fluclorolone acetonide
- Flumetasone
- Fluprednidene
|
|
| Pregnatriene |
|
|
| Androstene |
- Halogenated, with FG at 16: Fluticasone (Fluticasone propionate
- Fluticasone furoate)
|
|
| Others/unsorted |
- Halogenated: Loteprednol
- Halogenated, with FG at 16: Fludroxycortide
- Formocortal
- Mometasone furoate
- Promestriene
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|
|
Antagonists /
SGRMs |
- Antagonists: Ketoconazole
- Mifepristone
|
|
| Synthesis modifiers |
- Acetoxolone
- Aminoglutethimide
- Carbenoxolone
- Enoxolone
- Ketoconazole
- Metyrapone
- Mitotane
- Trilostane
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-
- #WHO-EM
- ‡Withdrawn from market
- Clinical trials:
- †Phase III
- §Never to phase III
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Index of hormones
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|
| Description |
- Glands
- Hormones
- thyroid
- mineralocorticoids
- Physiology
- Development
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| Disease |
- Diabetes
- Congenital
- Neoplasms and cancer
- Other
- Symptoms and signs
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| Treatment |
- Procedures
- Drugs
- calcium balance
- corticosteroids
- oral hypoglycemics
- pituitary and hypothalamic
- thyroid
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