Pharm

Topical Corticosteroid

Topical Corticosteroid, Topical Steroid, Clobetasol Propionate, Betamethasone Dipropionate, Triamcinolone Acetonide, Fluocinolone Acetonide, Hydrocortisone Cream, Hydrocortisone Topical, Halobetasol Propionate, Ultravate, Temovate, Diprolene, Diflorasone diacetate, Psorcon, Amcinonide, Cyclocort, Diprosone, Mometasone furoate, Elocon, Florone, Fluocinonide, Lidex, Maxiflor, Desoximetasone, Topicort, Halcinonide, Halog, Hydrocortisone valerate, Westcort, Kenalog, Flurandrenolide, Cordran, Betamethasone valerate, Valisone, Hydrocortisone butyrate, Locoid, Flucinolone Acetonide, Synalar, Alclometasone dipropionate, Aclovate, Desonide, Desowen

See Also

Background

Once daily dosing is as effective as 2-3 times daily dosing
1. Increased frequency does not improve outcomes and decreases patient compliance
2. Reapply after washing skin
3. Green (2005) Br J Dermatol 152:130-41 [PubMed]
Adjunctive measures: Occlusion
1. Increases potency of steroid 10 fold
2. Apply shower cap, plastic bag, vinyl suit, bandages or gloves
3. Use for stubborn areas
Vehicle
1. See Preparation Bases
2. Ointments (petroleum based)
  1. Thick, lubricating agents best applied to dry, hyperkeratotic smooth, non-hairy skin
  2. Least likely of topical agents to result in reaction (most inert with least additives)
  3. More potent than creams
  4. More greasy than creams
    1. Avoid on oozing lesions
    2. Avoid in intertriginous folds (e.g. axilla, groin) due to risk of maceration
    3. Avoid in moist or hot environment
3. Creams
  1. Mixture of water and oils
  2. Less occlusive and more drying than ointments
  3. Often contain additives (e.g. Alcohol) which may be irritating
  4. Preservatives may result in Contact Dermatitis
4. Lotions
  1. Higher water content than creams
  2. Least potent, least occlusive and least hydrating of vehicles
  3. Best used on hairy areas
5. Gels
  1. Water-based with rapid drying from skin, and with minimal residue
  2. Sting when applied to inflamed or fissured skin
  3. Best used on hairy areas, or for its drying effect
6. Foams
  1. Best used on scalp and other hairy regions (e.g. beard)
7. Solutions, Shampoos and Sprays
  1. Best used on thick hair regions
  2. Many solutions are Alcohol based and may irritate inflamed or fissured skin
Potency
1. Potency is based on Vasoconstriction assay (degree of Vasoconstriction with steroid application)
2. Tachyphylaxis (decreased effect with prolonged use) does not typically occur
3. Ointments are typically considered more potent than creams and lotions
  1. However, efficacy is typically equal among Preparation Bases
  2. Feldman (2005) Curr Ther Res Clin Exp 66(3): 154-71 [PubMed]
  3. Zivkovich (2009) J Drugs Dermatol 8(6): 570-2 [PubMed]
4. Topical Corticosteroids are divided into 7 classes
  1. Class 1: Very high potency
  2. Class 7: Very low potency
Quantity to prescribe (10 day supply for twice daily dosing)
1. See Topical Medication Quantity
2. Face and neck
  1. Finger Tip units: 2.5
  2. Adult: 30 g
  3. Child: 15 g
  4. Infant: 7.5 g
3. Hand (both sides)
  1. Finger Tip units: 1
  2. Adult: 15 g
  3. Child: 7.5 g
  4. Infant: 3.5 g
4. Foot (both sides)
  1. Finger Tip units: 2
  2. Adult: 30 g
  3. Child: 15 g
  4. Infant: 7.5 g
5. Arm
  1. Finger Tip units: 3
  2. Adult: 30 g
  3. Child: 15 g
  4. Infant: 7.5 g
6. Leg
  1. Finger Tip units: 6
  2. Adult: 60 g
  3. Child: 30 g
  4. Infant: 15 g
7. Trunk (front or back)
  1. Finger Tip units: 7
  2. Adult: 100 g
  3. Child: 50 g
  4. Infant: 25 g
8. Body
  1. Adult: 300 g
  2. Child: 150 g
  3. Infant: 75 g
Maximal Duration
1. Face, groin and intertriginous areas (skin folds)
  1. Limit duration to 1-2 weeks at a time
2. Very high potency (Class 1)
  1. Avoid use longer than 3 weeks
3. Medium to high potency (Class 2-6)
  1. Avoid use longer than 12 weeks
4. Low potency (Class 7)
  1. No specific maximal duration defined
References
1. Buys (2007) Am Fam Physician 75:523-8 [PubMed]

Risk Factors
Adverse Effects

High potency Corticosteroids (esp. class 1-2)
Young children
Thin skin (e.g. face, intertriginous areas)
Frequent or prolonged Topical Corticosteroid use

Example
Lower cost, generic steroids

Level 1: Clobetasol Propionate 0.05% ointment (price jump to $200 for 45 g in 2017)
Level 2: Betamethasone Dipropionate 0.05% ointment
Level 3: Betamethasone Dipropionate 0.05% cream
Level 4: Triamcinolone Acetonide 0.1% cream
Level 5: Triamcinolone Acetonide 0.1% lotion
Level 6: Fluocinolone Acetonide 0.01% cream
Level 7: Hydrocortisone 1% cream

Preparations
Level 1 (Ultra-High Potency)

Betamethasone Dipropionate augmented (Diprolene) 0.05% cream and ointment
Clobetasol Propionate (Temovate) 0.05% cream, ointment, lotion, gel, foam, solution, Shampoo, spray cream
Diflorasone diacetate (Psorcon) 0.05% ointment
Flucinonide (Lidex) 0.1% cream
Flurandrenolide 4 mcg/cm2 tape
Halobetasol Propionate (Ultravate) 0.05% cream and ointment

Preparations
Level 2 (Very High Potency)

Halcinonide (Halog) 0.1% cream
Amcinonide (Cyclocort) 0.1% ointment
Betamethasone Dipropionate augmented (Diprolene AF) 0.05% cream
Betamethasone Dipropionate (Diprosone) 0.05% ointment
Mometasone furoate (Elocon) 0.1% ointment
Diflorasone diacetate (Florone) 0.05% ointment
Fluocinonide (Lidex) 0.05% cream, gel, and ointment
Diflorasone diacetate (Maxiflor) 0.05% ointment
Desoximetasone (Topicort) 0.25% cream and ointment
Desoximetasone (Topicort) 0.05% gel

Preparations
Level 3 (High Potency)

Halcinonide (Halog) 0.1% ointment, Emollient, cream
Triamcinolone Acetonide (Aristocort A) 0.1% ointment
Amcinonide (Cyclocort) 0.1% cream and lotion
Betamethasone Dipropionate (Diprosone) 0.05% cream
Diflorasone diacetate (Florone) 0.05% cream
Fluocinonide (Lidex-E) 0.05% cream
Diflorasone diacetate (Maxiflor) 0.05% cream
Fluticasone propionate (Cutivate) 0.005% ointment

Preparations
Level 4 (Medium-High Potency)

Hydrocortisone valerate (Westcort) 0.2% ointment
Triamcinolone Acetonide (Kenalog) 0.1% cream
Flurandrenolide (Cordran) 0.05% ointment
Flucinolone Acetonide (Synalar) 0.025% ointment
Mometasone furoate (Elocon) 0.1% cream

Preparations
Level 5 (Medium Potency)

Hydrocortisone valerate (Westcort) 0.2% cream
Triamcinolone Acetonide (Kenalog) 0.1% lotion
Flurandrenolide (Cordran) 0.05% cream
Betamethasone Dipropionate (Diprosone) 0.05% lotion
Betamethasone valerate (Valisone): 0.1% cream, lotion
Hydrocortisone butyrate (Locoid) 0.1% cream
Flucinolone Acetonide (Synalar) 0.025% cream
Fluticasone propionate (Cutivate) 0.05% cream

Preparations
Level 6 (Low Potency)

Alclometasone dipropionate (Aclovate) 0.05% ointment and cream
Fluocinolone Acetonide (Synalar) 0.01% solution and cream
Desonide (Desowen) 0.05% cream and ointment

Preparations
Level 7 (Lowest Potency)

Hydrocortisone 1%, 2.5% lotion, cream, ointment,

Indications
Corticosteroid Potency Selection by Condition

High potency Corticosteroids (Level 1-3)
1. Alopecia Areata
2. Atopic Dermatitis (refractory cases)
3. Bullous Pemphigoid
4. Dermatitis in regions of thick skin (e.g. palms, soles)
5. Discoid Lupus
6. Dyshidrotic Eczema (esp. hands, severe cases)
7. Eczematous Dermatitis (severe cases)
8. Hyperkeratotic Eczema
9. Labial Adhesions
10. Lichen Planus
11. Lichen Sclerosus (skin)
12. Lichen Simplex Chronicus
13. Melasma
14. Nummular Eczema
15. Poison Ivy (severe cases)
16. Psoriasis
17. Vitiligo
Medium potency Corticosteroids (Level 4-5)
1. Asteatotic Eczema
2. Atopic Dermatitis
3. Dermatitis (severe)
4. Infantile Acropustulosis
5. Intertrigo (short-term use for severe cases)
6. Lichen Sclerosus (vulvar)
7. Nummular Eczema
8. Perianal inflammation (severe cases)
9. Scabies (only after the anti-Scabies agent has been used)
10. Seborrheic Dermatitis
11. Severe Intertrigo
12. Stasis Dermatitis
Low potency Corticosteroids (Level 6-7)
1. Dermatitis (face, Eyelids, diaper area)
2. Intertrigo
3. Perianal inflammation
4. Phimosis
References
1. Ference (2009) Am Fam Physician 79(2): 135-40 [PubMed]

Indications
Corticosteroid Potency Selection by Distribution

Low potency Topical Corticosteroids
1. Face
2. Groin
3. Intertriginous areas
Mid-potency Topical Corticosteroids
1. Thin skin trunk areas
2. Extremity lesions
High potency Topical Corticosteroids
1. Thick skin trunk areas
2. Extremity lesions
Very high or super-potent Corticosteroids
1. Very thick-skinned areas
2. Palms and soles

Adverse Effects
Topical Corticosteroids

Percutaneous absorption with systemic steroid effects
1. Systemic effects are uncommon with Topical Corticosteroids
2. Risk Factors for systemic effects
  1. Very high potency and high potency Topical Corticosteroids (level 1-3)
  2. Prolonged use of higher potency Topical Corticosteroids >2-4 weeks
  3. Large surface area of Topical Corticosteroid application
  4. High potency Corticosteroid on thin skin (e.g. face, axilla, groin)
  5. Children and Elderly (higher absorption)
3. Mitigation of systemic effects
  1. Limit high potency Corticosteroids to 2-4 weeks of use
  2. Consider pulse dosing of Topical Corticosteroid (2 weeks on, 1 week off)
  3. When appropriate, use lower potency Corticosteroids
4. Systemic Corticosteroid Effects
  1. Cushing Syndrome
  2. Adrenal suppression
  3. Growth Delay
  4. Steroid-Induced Hyperglycemia
  5. Aseptic Necrosis of the Femoral Head
  6. Hypertension
  7. Peripheral Edema
Skin atrophy
1. Skin fragility
2. Easy Bruising
3. Pigment change (Hypopigmentation, Hyperpigmentation)
4. Petechiae, Purpura and Telangiectasias
5. Skin Ulcers
6. Striae formation
Rebound papular dermatitis after medium-high potency
1. Avoid high potency steroid on genital or face
Secondary or provoked Skin Infections
1. Masked Tinea Infection
2. Granuloma gluteale infantum
Eye affects (if exposed)
1. Glaucoma
2. Cataracts
Corticosteroid withdrawal effects (rebound inflammation after stopping steroid)
1. Most common on the face and genitalia
2. Erythema, edema and skin Scaling
3. Stinging and burning
4. Papules and Pustules
Other effects
1. Acne Rosacea
2. Acne Vulgaris
3. Contact Dermatitis
4. Delayed Wound Healing
5. Hypertrichosis
6. Periocular Dermatitis
7. Photosensitivity
8. Superficial Folliculitis
References
1. Hengge (2006) J Am Acad Dermatol 54(1): 1-15 [PubMed]

Safety

Topical Corticosteroids appear safe in pregnancy and Lactation
1. Use the lowest potency effective Topical Steroid
  1. Hydrocortisone 0.5 to 1% applied twice daily for up to 10 days (most safety data)
2. Avoid high potency steroids and prolonged steroid use
  1. Risk of hypothalamic-pituitary-adrenal axis suppression
  2. May provoke Hyperglycemia and Hypertension
3. References
  1. Chi (2015) Cochrane Database Syst Rev (10): CD007346 [PubMed]
  2. Hengge (2006) J Am Acad Dermatol 54(1): 1-15 [PubMed]

References

(2021) Presc Lett 28(5): 29
(2018) Presc Lett 25(1): 5
Kaplan (2001) CMEA Medicine Lecture, San Diego
Stacey (2021) Am Fam Physician 103(6): 337-43 [PubMed]