Topical Corticosteroids

Dr.Bhavesh Pansuria
(BAMS)

Topical corticosteroids

Topical steroids have revolutionized the practice of

dermatology since they were introduced in the late
1950s.
They are effective preparations used to control
eczema/dermatitis and many other skin conditions.
They are also called topical corticosteroids.
The topical steroids can be divided up into seven
groups according to their strength.
As a general rule, use the weakest possible steroid
that will do the job. However, sometimes it is
appropriate to use a potent preparation for a short
time to make sure the skin condition clears completely.

Topical corticosteroids

MOA:
Anti-inflammation
Immunosuppressive
Antiproliferative

Corticosteroids exerts their Anti-inflammatry

effects through the following mechanism:-Vasoconstriction
-Stabilization of lysosomal membrane
-Inhibition of prostraglandins & leucotrienes
synthesis by blocking phospholipase
-Decreased chemotaxis of pro inflammatory
cells at the site of inflamation

Corticosteroids exerts their

Immunosuppressive effects through the
following mechanism:-Induction of lymphocytes and eosinophil
apoptosis
-Depletion of langerhans cells in the
epidermis & dermis
-Decreased IL-2 production by T-cells

Corticosteroids exerts their Antiproliferative

effects through the following mechanism:-Inhibition of mytosis of kerationcytes
-Inhibition of synthesis of dermal fibroblasts
& subsequent collagen, elastin &
glycosaminoglycans
-Corticosteroids bind to cytosolic receptors &
affects transcription & translation

Topical corticosteroids interrupt the inflammatory cascade at key,

early stages of the disease, limiting production of inflammatory
precursor proteins at a nuclear level and controlling the increase of
mast cells and lymphocytes at the cellular level.

Inhibit phospholipase A2 which reduces

skin levels of pro-inflam kinines:
-Arachidonic acid
(Omega-6, s inflammation)
-Prostaglandins
(s vascular dilation)
-Leukotrienes
(inflammatory response)

Use
erythema
scaling &
pruritus

High-potency steroids
(groups I to III)

Alopecia areata
Atopic dermatitis
(resistant)
Discoid lupus
Hyperkeratotic
eczema
Lichen planus

Lichen sclerosus
(skin)
Lichen simplex
chronicus
Nummular eczema
Poison ivy (severe)
PsoriasisSevere
Hand eczema

Medium-potency
steroids (groups IV
and
V)
Anal inflammation
Scabies (after

(severe)
Asteatotic eczema
Atopic dermatitis
Lichen sclerosus
(vulva)
Nummular eczema

scabicide)
Seborrheic
dermatitis
Severe dermatitis
Severe intertrigo
(short-term)
Stasis dermatitis

Low-potency steroids
(groups VI and VII)

Dermatitis
(diaper)
Dermatitis
(eyelids)
Dermatitis (face)

Intertrigo
Perianal
inflammation

Choosing a topical
steroid

Many topical steroids available

Different vehicles
Differ in potency and formulation
Weaker: thin-skinned, sensitive areas

axillae, groin, perianal, breast folds, face, eyelids

Moderate:

trunk, arms, legs

Strong: thick-skinned areas

palms, soles, certain dermatitis such as lichen

planus and psoriasis

Choice of vehicle

Steroids may differ in potency based

on the vehicle in which they are
formulated.
The choice of vehicle depends on the
anatomical site to be treated and the
condition of the skin.
As a rule, acutely inflamed skin is best
treated with fairly bland preparations
which are least likely to irritate.

Moist or exudative eruptions are

conventionally treated with wet
medications such as lotions or creams.
Dry skin responds well to the occlusive
action of ointments
Hair bearing skin, especially the scalp,
can be treated with medicaments
formulated into shampoos, lotions, gels
or mousse.

Ointments

Most effective
Ointment have oily/greasy base (ie:petroleum jelly)
Greasy texture persists on the skin surface
Translucent
Best lubrication, penetration
Best for dry or thick, hyperkeratotic lesions
Not recommended for hairy areas & areas where
skin touches skin or acute vesicular or weeping
rashes
Poor pt satisfaction / compliance b/o grease nature.

Creams

Most often prescribed

Water suspended in oil
White color/ less greasy/ vanish into the skin
Good lubricating/ emollient qualities
USE:
most skin areas, useful where skin touches skin
(groin, rectal area, armpits )
acute exudative inflammation b/c of drying effect
w/ repeated use
Generally less potent than ointments of the same
medication,
Often contain preservatives (cause irritation,
stinging, allergic reaction)

Lotions

Lotion: Bases contain water, alcohol,

other chemicals
Clear or milky appearance
Least greasy & occlusive
Drying effect on an oozing lesion
Useful for use on the scalp b/c no
residue
Can cause stinging and drying
Cordran tape

Gels

Gels: Mixture of propylene glycol

(drying) & water
Clear color, nongreasy,
Jelly-like consistency
Use: exudative inflammation(poison
ivy)
"wet" rashes ,scalp

Foams
Use:
Hairy areas
Expensive
Drying

Potency

There are seven groups of topical

steroid potency, ranging from ultra high
potency (group I) to low potency (group
VII).

Fluorinated topical steroids are

generally more potent than others
ie: triamcinolone acetonide (contains
fluoride ion) is 100x more potent than
nonfluorinated HC

Topical Steroids
Potency
I: (Most Potent)
Clobetasol propionate

0.05% (cream,
ointment,
solution)

Betamethasone
dipropionate

0.05% (optimized
vehicle; ointment)

Halobetasol propionate

0.05% (cream,
ointment)

Diflorasone diacetate

0.05% (optimized
vehicle;
ointment)

II: High
Betamethasone valerate

0.1% (cream)

Betamethasone
dipropionate

0.05% (ointment)

Mometasone furoate

0.1% (ointment)

Halcinonide

0.1% (cream)

III: Medium high

Triamcinolone acetate

0.1% (ointment)

Flucinonide

0.05% (cream)

Fluticasone propionate

0.005% (ointment)

Betamethasone
dipropionate

0.05% (cream)

IV: Medium
Triamcinolone acetonide

0.1% (ointment)

Hydrocortisone valerate

0.2% (ointment)

Mometasone furoate

0.1% (cream)

Fluocinolone acetonide

0.025% (ointment)

Methylprednisolone
aceponate

0.1% (cream)

V: Medium Low
Fluticasone propionate

0.05% (cream)

Betamethasone benzoate

0.025% (cream)

Betamethasone valerate

0.1% (cream)

Triamcinolone acetate

0.15% (lotion)

Hydrocortisone butyrate

0.1% (cream)

Hydrocortisone valerate

0.2% (cream)

VI: Low
Aclometasone
dipropionate
Fluocinolone acetonide

0.05% (cream,
ointment)
0.01% (cream,
solution)
0.05% (cream)

Desonide
Betamethasone valerate 0.1% (lotion)

VII: Least potent

Hydrocortisone

0.5%, 1%, 2.5%

Dexamethasone

0.1% (cream)

Methylprednisolone

1%

Regional Differences in
Penetration: Most to
Least

1. Mucous membrane
2. Scrotum
3. Eyelids
4. Face & scalp
5. Chest & back
6. Upper arms & legs
7. Lower arms & legs
8. Dorsa of hands & feet
9. Palmar & plantar skin
10. Nails

General Rules of Use

Based on Location
Potency

Sites

Low

Babies skin, face, genital skin, skin

folds

Intermediat Similar to Low, but where skin is

e
more
thickened/chronic
High

Scalp; thick or chronic skin lesions

Ultra-high

Elbows, hyperkeratotic dermatoses,

knees, palms, soles

Application tips

Children/elderly:
avoid potent fluorinated compounds

Face:
only non-fluorinated
mild unless severe dematitis

Better to use super-potent briefly

than mild
ineffective long term

Frequency of
Administration

QD or BID application
No improved result for more frequent
administration
Chronic application can induce
tachyphylaxis (tolerance)
Max 3wks for ultra-high-potency
steroids

Amount of application

Titrate to the minimal amt needed

Prevent tachyphylaxis:
1wk on, 1wk off or 3d on,4d off
taper off
hi potent for flare, low for control.
Amount: does not affect penetration or potency
Thick application is wasted
Only thin layer in intimate contact w/ skin is
absorbed
Absorption: Thin to thick stratum corneum:
mucous membranes -> scrotum-> eyelids-> face->
torso-> extremities-> palm,soles, elbows, knees
Inflamed skin: less barrier, better absorption

Amount Required
Area
Treated

1
Applicatio
n (g)

Bid for 1
Week (g)

Bid for 1
Month (g)

Ano-genital, 2gm
face, hands,
head

28gm

120gm

1 arm,
posterior or
anterior
trunk

3gm

42gm

180gm

1 leg

4gm

56gm

240gm

Entire body

30gm
60gm

420gm
840gm

1.83.6 kg

Dosing-FTU Fingertip
unit

Fingertip units is a term coined by CC Long and AY

Finlay who, in an article published in 1991 ,
described a convenient way to measure how
much cream to prescribe to a patient with skin
disease. Accurate prescription is particularly
important for topical steroids.
A fingertip unit describes
the amount of cream
squeezed out of its tube
onto the end of the
finger as shown.

Dose of cream in a
fingertip unit varies with
age:

Adult male: one fingertip unit provides

0.5 g
Adult female: one fingertip unit provides
0.4g
Children of four years approximately
1/3 of adult amount
Infants six months to one year
approximately 1/4 of adult amount

Use the adult fingertip unit as your guide

Finger-tip measurements
1 finger-tip length = 0.5gm
2 finger-tip lengths = 1gm
1 pump unit = 1gm

Topical steroids:
approximate single
application requirement
child0.5 g
Child
Face and
neck

0.5 g
One arm

2g
Trunk (front
and back)

1g
One leg

1g
Hands and
feet

Topical steroids:
approximate single
application requirement
adult1.5 g
Adult
Face and
neck

1.5 g
One arm

7g
Trunk (front
and back)
1g
One hand
3g
One leg
1g
One foot

Example

An adult female applies a cream once daily to both arms.

She uses 2.4g in one day (2 arms x 3 fingertip units x 0.4g
= 2.4 g). This is 16.8g/week(7 x 2.4 g).
A 30 g tube should last her two weeks. But if she applies it
twice daily (4.8g/day), the tube will be finished in less than
a week (33.6g/week).
An adult male applies a cream once daily to both feet and
both hands. He uses about 3 g per day (2 feet x 2 units
PLUS 2 hands x 1 unit, x 0.5 g = 3.0 g). This works out as
21 g/week (7 x 3 g).
A 50 g tube should last him about 2 1/2 weeks.
A baby has a cream applied twice daily to the entire body,
i.e. about 10 g daily.

Side effects of topical

steroids
Like all medications, topical corticosteroids are
associated with potential adverse effects (side
effects) especially if they are used incorrectly.
- Systemic side effect
- Local side effect

Systemic side effects

-If more than 50g of clobetasol propionate, or 500g of
hydrocortisone is used per week, sufficient steroid may
be absorbed through the skin to result in adrenal gland
suppression and/or eventually Cushing's syndrome.
-Adrenal Gland Suppression.
Topical steroids can suppress the production of natural
steroids, which are essential for healthy living. Stopping
the steroids suddenly may then result in illness.
-Cushing's Syndrome If large amounts of steroid are
absorbed through the skin, fluid retention, raised blood
pressure, diabetes etc. may result.

Local side effects

Local
side effects Remarks/ Predospind factors

Skin side effects

Skin Atropy

Thin skin of eyelids, genitals, children

Vascular purpura

Dependent areas, scury,collegen vascular

disorder

Telangiectasia

Senil skin, infants & children

Hypopigmentation

Is commonly perilesional??

Striae

Obesity, pregnancy, potent steroids

Allergic contact

Due to vehical or steroid molecule

Cutneous
candidiasis

Diabetes, pt. on cytotoxic therapy &

Malignancies

Poor wound healing Diabetes

Hypertrichosis

Reversible

Local side effects Remarks/ Predisposing factors

Folliculitis & other
bacterial infection

Pre existing cutaneous infection, diabetes,

neuropathic patients, immuno deficiency,
steroids in ointment form

Miliaria

TCS under occlusion, TCS over occluded

sites like flexures

Perioral dermatitis

Fluorinated steroids & potent steroids over

face, use of cosmetics

Steroid induced
Rosacea

Flurinated steroid & potent steroid over

face

Acneform eruption

Monomorphic papules mostly on back, no

comedones & inflammatory lesions

Tachyphylaxis

Sudden decrease in the response to a

drug after its administration

The risk of these side effects depends on the

strength of the steroid, the length of
application, the site treated, and the nature of
the skin problem.
If you use a potent steroid cream on your face
as a moisturiser, you will develop the side
effects within a few weeks.
If you use 1% hydrocortisone cream on your
hands for 25 years, you will have done no
harm at all (except for having wasted a lot of
money!)

Key Points

Topical steroids are very effective medications.

They work by reducing inflammation, and when
used correctly are very safe.
They should not be used as bleaching creams.
Apply topical steroids only to the areas
affected by the skin disease, and generally
only once or twice daily.
If your skin is dry, apply an emollient
frequently.

Allergy associations

The highlighted steroids are often used in the

screening of allergies to topical steroid and systemic
steroids. 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,
methyprednisolone, 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-17valerate, aclometasone dipropionate,
betamethasone valerate, betamethasone
dipropionate, prednicarbate, clobetasone-17butyrate, clobetasol-17-propionate, fluocortolone
caproate, fluocortolone pivalate, and fluprednidene
acetate

Intralesional steroid
therapy

Steroids in liquid form are injected in

different conditions of the skin to
produce a localized response.
Usually after cleaning the skin 0.2ml to
0.3ml are injected in each area upto 10
different areas of the skin are chosen.
The procedure in itself is quite
powerful.

The technique requires the right

placement of the steroid in the skin.
Too deep a placement can cause
unnecessary side effects without a
local response.

Indications

Keloids
Alopecia areata
Prurigo nodularis
LSC
Hypertrophic
lichen planus
Hemangiomas
Pemphigus vulgaris

Nodular scabies
Reiters disease
Granuloma cheilitis
DLE, mild LE
Nodulocystic acne
Localized
recalcitral psoriasis

Steroids used for

Intralesional injections
Steroid

Dose

Preparation

Triamcinolone 10mg
Kenacort
acetonide
IL,40mg every 10mg/ml
4 weeks
40mg/ml
Hydrocortison 25mg IL,
e (depot
every 4
preparation) weeks

Wycort
25mg/ml vial

Methyl
prednisolone
acetate

Depomedrol
10mg/ml,
40mg/ml

10mg IL,
every 4-8
weeks

Advantages over
topical and oral
steroid
The injection of a steroid into the skin

has two advantages over topical and

oral steroid treatment;
1)It will be more effective in treating
deep-seated conditions than a steroid
cream or ointment.
2)It will have only a local effect rather
than the general effects of a steroid
taken orally.

Side Effects

Immediate side effects:

Pain (even vasovagal or neurogenic
shock can occur)
Bleeding
Infection & Abscess
Allergic reaction
Swelling
Amaurosis fungax (transient monoocular blindness due to accidental
intrasvascular injection

Subsequent side effects:

Atrophy
Telangiectasia
Hypopigmentation
Hyperpigmentation
Purpura
Striae-particularly when i/l is given over
breast
Treatment may not be effective, or the
condition may recur.

Key Points

For anti inflammatory indications, dose of

intralesional steroids is 5mg/ml
While in keloids it is 40mg/ml
Intralesional delivery of steroids can be
done with insuline syringe with 25G
needle or by fast, painless jet of steroid
lotions into the skin by special instrument
available for this purpose (Dermajet), the
latter is especially helpful in children.

Thanks for your

patience