Rational and ethical use of topical corticosteroids based on safety and efficacy.

Topical corticosteroids (TC) have greatly contributed to the dermatologist's ability to effectively treat several difficult dermatoses. The available range of formulations and potency gives flexibility to treat all groups of patients, different phases of disease, and different anatomic sites. However, the rapid rise in incidence of improper use of these drugs by dermatologists, general physicians, and patients threatens to bring disrepute to the entire group of these amazing drugs. Responsibility to disseminate proper knowledge regarding when, where, and how to use TC both to internists and patients rests primarily with the dermatologist. Benefits of rational and ethical use and the harm of overuse and misuse for nonmedical, specially for cosmetic purposes, should be clearly conveyed before penning a prescription involving TC. Simultaneous efforts to use political, legal, and other institutions to prevent misuse of these drugs by rationing their availability only through proper prescriptions will greatly help the cause. This will hopefully bring down both the extremes of ever increasing cases of steroid-induced dermatoses on one hand and the irrational fears of using TC in well justified indications on the other.

Introduction

The topical corticosteroids (TC) are among the most commonly prescribed medication in an out-patient dermatology setting since they were first introduced in early 1950s.[1-3] Probably no other group of drugs has had such a profound impact on the speciality as TC. Using them, it has become so much easier to treat several dermatoses which otherwise were the cause of significant morbidity among people.

However, over the years it has become increasingly apparent that TC are being abused by doctors and patients alike. Apart from the well-known indications such as psoriasis, atopic dermatitis, vitiligo, lichen planus, lichen simplex chronicus, discoid lupus erythematosus, etc., they are being used for conditions such as melasma, urticaria, and even undiagnosed skin rash by dermatologists and general physicians.[4] This is because of the quick amelioration of signs and symptoms of many skin disorders by the application of TC in the first instance. This can buy time and hold patient a while longer more so with a nonspecialist. Studies in patients presenting with steroid-related eruptions have shown that there are several nonmedical advisers like friends, neighbors, beauticians, barbers, etc. telling them to use it as fairness/cosmetic creams,[5] anti-acne, anti-fungal therapy and for that matter any skin eruptions.[6] There is a tendency to reuse old prescription for a recurrent or new rash. Prescription sharing with relatives and friends on the presumption that similar looking skin problems can be self-treated by simple prescription copying is rampant. To compound this problem, there is easy availability of these drugs almost for the asking without a valid prescription at every chemist shop. Moreover, store pharmacists also double up as doctors doling out advice about which TC to use. These instances, although reported from many places worldwide,[7-9] have significant impact in our country of a billion plus people with an adverse specialist-to-patient ratio.

The awareness of this significant problem has led to a flurry of activity as evidenced by discussions about TC misuse by dermatologists at various forums in the country and abroad.[510-12] Presently, the hope is to contain, if not entirely, reverse TC misuse due to the prevailing situation in our country. As a dermatologist, the onus of responsibility lies on us, for whom these drugs are a strong weapon to fight many skin diseases, to correctly educate the society including our non-dermatologist medical fraternity about ethical and rational use of TC. It is good to recall the Biologist Van Rensselaer Potter who proposed the term “bioethics” in 1970,[13] to encompass a field that lay at the intersection of ethics and the biological sciences in general. The primary goal underlying all ethical issues in health care, in our case the use of TC, is to see that the knowledge gained through research should benefit and not cause harm to the society and that knowledge should be disseminated correctly.

Choosing Topical Corticosteroid

A bunch of TC is available for the management of dermatoses. A basic understanding of them certainly helps clinicians to select appropriate preparations that maximize therapeutic efficacy and minimize the potential for adverse effects. For successful treatment with TC, key factors to be considered are accurate diagnosis, selecting the correct drug, keeping in mind the potency, delivery vehicle, frequency of application, duration of treatment and adverse effects, and proper patient profiling.[4]

Know the Disease

The TC are effective for skin conditions that are characterized by hyper-proliferation, inflammation, and immunologic involvement.[14] They are also widely used in the treatment of vesiculo-erosive diseases of the oral mucosa to reduce pain and inflammation.[15] They can provide symptomatic relief for burning and pruritic lesions.[16] Many dermatoses are treated with TC [Table 1], but evidence of effectiveness has been established only for a small number of conditions. It is important to prescribe TC only after having a correct diagnosis in a patient and for those dermatoses where there is reasonable evidence of efficacy. We should strongly resist the temptation to use TC for everything that we do not understand or where nothing else is working. This may provide temporary benefits, but makes diagnosis even more difficult for the next time apart from exposing the patient to the risk of adverse effects. Knowing the correct indication, different strengths of topical steroids may be used to treat different phases of the disease.

Table 1

Steroid responsive dermatoses

Know the Drug

Potency

Potency is the amount of drug required to produce a desired therapeutic effect. The potency of TC is usually assessed by measurement of vaso-constrictive properties.[17] This helps to classify TC based on the extent to which the agent causes cutaneous vasoconstriction (‘blanching effect’) in a normal, healthy person. This is a useful but not perfect method for predicting the clinical effectiveness of steroids.[18] In fact, the anti-inflammatory potency of some TC may vary among patients, depending not only on the strength of the formulation but also on the frequency of administration, the duration of treatment, and sites of application.[1920] Sometimes potency may also differ between generic formulations and their brand name equivalent.[16]

Since the time hydrocortisone was first shown to be clinically effective as a topical preparation in 1952, the molecule has been structurally modified by halogenation, methylation, acetylation, esterification, etc. with the aim to increase potency and reduce adverse effects.[16] The ideal TC is yet to be developed. Modifications such as halogenation increase the potency but also the adverse effects.[21] Esterification has been reported to improve the safety profile while increasing the efficacy of TC.[22]

TC are divided into four groups according to their potency in keeping with the British National Formulary (BNF), while American system classifies them into seven classes,[23] with class I being the super potent or ultra potent and class VII represent the least potent [Table 2]. Although a thorough knowledge of drugs in each class may be ideal, practically a physician should become familiar with one or two agents in each category of potency to safely and effectively treat steroid-responsive skin conditions.

Table 2

Relative potency of topical corticosteroids*

As a general rule, low potency steroids are the safest agents for long-term use, on large surface areas, on the face, or on areas with thinner skin and for children. More potent TC are helpful for severe disease and for thicker skin of palms and soles. High and ultra-high potency steroids should not be used on the face, groin, axillae, and under occlusion; except in rare situations and for short duration.[24]

Vehicle

TC are available in several formulations and with varying strength, which may differ in potency based on their vehicle in which they are formulated. The selection of vehicle depends on the type of lesions and the anatomical region. They are available in ointments, creams, gels, lotions, solutions, etc.[25]

Ointments provide more lubrication and occlusion than other preparations and are the most useful for treating dry and thick, hyper-keratotic lesion. Their occlusive nature adds on to improve steroid absorption. However, they should not be used on hairy area and may cause maceration and folliculitis, if used in intertriginous areas and their greasy nature may result in poor patient satisfaction and compliance.[4]

Creams have good lubricating qualities and their ability to vanish into the skin make them cosmetically appealing. For acute exudative inflammation and in intertriginous areas, creams are better for their nonocclusive and drying effect. Creams are generally less potent than ointment of the same medication, but they often contain preservatives which can cause irritation, stinging, and allergic reaction.[4]

Lotion and gels are the least greasy and occlusive of all topical steroid vehicles. Lotions are useful for hairy areas because they penetrate easily and leave little residue. Gel dry quickly and can be applied on the scalp or other hairy areas as they do not cause matting.[2627] Foams and mousses and shampoo are effective vehicle for delivering steroid to the scalp but are costly.

Occlusion increases steroid penetration and can be used in combination with all vehicle. Simple plastic dressing results in a seven-fold increase in steroid penetration compared with dry skin.[16] However irritation, folliculitis and infection can develop rapidly from occlusive dressings and patients should be counseled to monitor the treatment site closely. Applying a topical steroid after a shower or bath improves its effectiveness due to hydration.[28] Flexural areas such as groin, axillae, infra-mammary are self-occlusive where vehicles such as ointments should be avoided.

Dose, frequency of application, and duration

Sometime the most well-meaning dermatologist and other medical care givers fail to spend enough time with the patient. All of us come across instances when vastly different clinical efficacy and/or adverse effect profile is seen for the same TC given for similar indication in two different patients. This is because without proper guidance, patients differ greatly in the way they would use TC in terms of the amount, the frequency, and duration of use thus causing differences in the efficacy and the harm profile they experience. Rational use involves putting across proper guidelines in this area.

With regards to the quantity of TC, the standardized technique devised by Long and Finley,[29] which uses the “finger tip unit” (FTU), has been recommended to measure the amount of ointment necessary for a specific anatomic area. A FTU is defined as the amount that can be squeezed from the finger tip to the first crease of the finger with a 5 mm diameter nozzle. Using a standard nozzle tube, one FTU equals 0.5 g cream/ointment.[30]

The use of FTU is greatly promoted worldwide to reduce the variation in uses of TC and to encourage adherence to therapy. The recommended doses in terms of FTU will depend on which part of the body is being treated. This is because the skin is thinner in certain parts of the body and more sensitive to the effects of TC. Tables 3 and 4 show guidelines as to the amount of ointment needed in adult and children, respectively, based on specific anatomic areas.

Table 3

FTU guidelines for adults*

Table 4

FTU guidelines for children*

In practice once or twice daily application is recommended for most conventional TC preparations.[16] Some newer formulations have been prepared for once daily application.[31] Even for the former, more frequent administration does not provide better results.[32] In atopic dermatitis a well-documented steroid responsive dermatosis, 10 randomized controlled trials compared once daily versus more frequent applications of ten within the same potency group were reviewed. The findings are summarized in UK Health Technology Assessment report and guidance from the National Institute for Health and Clinical Excellence (NICE).[33] None of the studies found clear evidence that applying TC more than once a day produced better overall clinical outcomes in eczema. On the other hand, frequent use of TC leads to several local and systemic side effects. A change to once daily application was suggested several years ago. Perhaps the biggest barrier to this has been our habit.[34]

It is also a well known fact that the stratum corneum acts as a reservoir for TC. An ultra-potent TC such as clobetasol propionate 0.05% cream was found to persist in stratum corneum till day four.[35] Due to this cumulative depot effect, an alternate or even twice a week application of TC can be advocated. Once a condition is in remission or under desired control weekend TC separated by weekdays of emollients or steroid sparing agents also is quite rewarding. By doing so, the benefits of the therapy can be maximized, the cost can be reduced, and local and systemic adverse effects of TC can be decreased.[1436] All these factors will improve the patient compliance. For an individual patient, the optimal dosing schedule can be determined by trial and error, titrating to the minimum frequency of application that still provides relief.

Generally most of the TC, regardless of the potency, should not be used for more than 2–4 weeks duration at a stretch. If there is worsening of the lesions or no change noticed, the product needs to be discontinued and re-evaluation of the diagnosis is needed. Super potent and potent preparations are specifically recommended for a maximum duration of only 2 weeks followed by a tapering regimen for maintenance to avoid adverse effects.[416]

Adverse effects of TC

TC are used primarily for their anti-inflammatory properties. Paradoxically, the same mechanisms which mediate their anti-inflammatory properties and underlie their usefulness are also responsible for their adverse effects.[37] Besides the cutaneous and systemic adverse effects [Table 5], the phenomenon of steroid addiction, tachyphylaxis, and contact dermatitis (CD) due to TC also needs to be borne in mind.

Table 5

Common adverse effects of topical corticosteroids*

Local effects

They are encountered more frequently and have become more prevalent with the introduction of high potency TC.[30] These side effects depend on potency of steroid, duration of use (i.e. extended period), volume of the product applied (i.e. excessive amount), site of application, age of the patient and occlusion (if present).

These include, atrophy, striae, telengiectasis, purpura, hypo-pigmentation, acneiform eruptions, rosacea-like perioral and periorbital dermatitis, and hypertrichosis.[38-53] The normal presentation of superficial infections can be altered when TC are inappropriately used to treat bacterial or fungal infections. A typical example of this is seen when someone applies a TC to an itchy groin rash. If this is a fungal infection, the rash gets redder, itchier, and spread more extensively than a typical fungal infection. The resulting rash is a bizarre pattern of widespread inflammation with pustules called tinea incognito [Figure 1].

Figure 1

Bizarre pattern of tinea cruris (tinea incognito)

Due to inappropriate and uncontrolled use of TC, an under reported and under stressed entity has evolved, namely TC addiction. Convincing arguments have been put to consider several erythema syndromes such as red face syndrome, post-peel erythema, red scrotal syndrome, vulvodynia, perianal atrophoderma, chronic actinic dermatitis, and chronic recalcitrant eczemas under the umbrella of steroid addiction.[5455] Prolonged and continuous uses of TC on face lead to the development of dermatoses which has been named variously by different workers. In our scenario, it is called “topical corticosteroid-induced rosacea-like dermatitis” (TCIRD)[10] or “topical steroid-dependent face” (TSDF).[11] This has a distinct clinical presentation. Patients are mostly females who keep on using the steroidal cream till they get magical response and continue it later to prevent rebound flare till finally the lesions become persistent [Figure 2].

Figure 2

Erythema with papulo-pustules on face (TCIRD)

Systemic effects

Topically applied high and ultra high potency TC can be absorbed well enough to cause systemic side-effects. Hypothalamic-pituitary-adrenal suppression, glaucoma, hyperglycemia, hypertension, and other systemic side-effects have been reported, though rare.[54-58]

Most of the adverse reactions may be reversible to some extent upon discontinuation, with the exception of atrophic striae [Figure 3], which are not reversible.[416] Rebound of pre-existing dermatoses has also been reported to occur with abrupt discontinuation, especially with potent preparations. TCIRD/TSDF is very difficult to manage due to a compromised epidermal barrier as well as due to rebound flare up of skin lesions.[1011]

Figure 3

Atrophic striae on groin

It has been suggested that corticosteroid effects are due to their action on gene expression by two different mechanisms; transrepression responsible for most therapeutic effects and transactivation which mediates a large proportion of adverse effects. Selective novel glucocorticoid receptor agonists are being developed that exhibit relative dissociation between transrepression and transactivation. This may in future lead to development of a novel class of TC devoid of significant adverse effects.[59]

Tachyphylaxis

It is the tolerance that skin develops to the vasoconstrictive action of TC. After repeated use of topical steroids, the capillaries in the skin do not constrict well, requiring higher dose or more frequent application of the steroid. The ability of the blood vessels to constrict returns four days after stopping therapy.[6061]

It is now suggested that either poor patient compliance or the natural course of disease activity (unrelated to the therapy) may be the main reason behind tachyphylaxis.

For this reason, instituting, “weekend therapy” or “pulse therapy” may at least resolve the compliance issue. If a TC loses its effectiveness, it should be discontinued for 4–7 days and then restarted.[16]

Cross sensitization and cross reactivity

Contact dermatitis due to TC is not uncommon. The estimated prevalence was found to be in the range of 0.2–6% in previous studies.[62-67] Nonfluorinated corticosteroids are more likely to cause CD. It should be considered whenever there is no satisfactory resolution, or worsening of lesions after excluding exacerbation of an undiagnosed infection. Sometimes worsening of a longstanding chronic expanding eczematous rash despite TC use may be due to the phenomenon of corticosteroid addiction, a well-defined entity which may be mediated by an underlying increase in serum nitric oxide levels.[68] It is worthwhile to know whether there is true sensitivity to the TC itself or to one of the constituents or preservatives present in the vehicle. A skin patch test can be used to detect and confirm sensitivity to corticosteroids.

Know the patients

It helps to keep in mind the age, sex, underlying special physiological conditions like pregnancy, lactation, and also the expectation of the patient besides the site and extent of involvement when prescribing TC.[1430]

TC have to be used with caution in children and elderly due to larger surface area to body weight ratio and poor skin barrier function in the former and skin fragility in the latter, respectively.[69] Female patients are more prone to steroid adverse effects due to their tendency to use TC indiscriminately. Since there are no well-controlled studies of the teratogenic potential of most of the TC in pregnancy, they are categorized as pregnancy category C and thus recommended to be used only if the potential benefit justifies the potential risk to the fetus.[38] During lactation, they are to be used with caution. It is known that peer pressure, rapid feel good effect, and ignorance about harmful effects of TC also lead to continuation of treatment beyond prescribed time.[9] Time spent in educating on these points will prevent mishaps. It will also take care of the other extreme of excessive fear of using TC which leads to inadequate usage and poor clinical results.

In normal healthy skin, absorption of TC varies from region to region. Penetration varies between the eyelids and the sole by nearly 300 folds.[70] In diseased states, due to defective epidermal barrier, the penetration of TC can be two to ten folds higher. Areas with thick stratum corneum, such as palms and soles need to be treated with high potency preparations.[430] Conversely, areas with thin stratum corneum such as eye lid or areas of occlusion like groin and axilla and other intertrigenous areas need to be treated with medium to low potency preparations.[1430] In the flexural areas, as mentioned before there will be the additional physical effect of occlusion by skin folds that will also enhance absorption. When large surface areas are involved, treatment with a low to medium potency preparation is needed because of the increased risk of systemic absorption. Monitoring of all these variables is constantly required for treatment with TC to be safe and effective.

Conclusions

We will quickly realize that despite the best efforts undertaken at our level, many of these problems will continue to persist because they were not contributed by us alone. To address them, interventions have to be multidimensional, involving political, educational and legal approaches.[9] Opportunity may have to be seized by the leadership of Indian Association of Dermatologists, Venereologists and Leprologists at every available forum. Political leaders and government officials should be repeatedly apprised of the prevailing situation and the need to curb this menace. Use of media for public education on topical steroid misuse is warranted, and the involvement of general practitioners, nurses. and pharmacists is needed. The legal approach should include the enforcement of the existing legislation related to the control of these drugs, so that TC are not sold without proper prescriptions. Pharmaceutical companies should be made to ensure proper labeling of TC products which should include inserts containing clear “finger tip unit” instruction, preferably with images and chart to show the numbers of unit required for specific areas of the body.[71] This will greatly help in optimal and safe use of TC. The legal aspect should also include measures aimed at strengthening the ethical responsibilities of pharmacists in correctly advising patients about the safety of medicines bought over the counter. Once the measures are in place and working, we hopefully may see the beginning of the reversal of the misuse/abuse of TC and the consolidation of the well-established benefits of this wonderful group of drugs.

Optimizing the use of TC

To prescribe for the appropriate dermatoses.

To use appropriate potency and strength of TC to achieve disease control.

To maintain with a less potent preparation or reduce frequency of application after satisfactory response.

To taper off the treatment upon complete remission of skin diseases.

To be extra careful when prescribing topical steroid over certain locations (e.g. scrotum, face, and flexures).

To be especially considerate when prescribing to the elderly and children.

To be aware of the adverse effects and act immediately to counteract them.

To avoid home-made dilutions of TC and prescribing TC in combination with antimicrobial and antifungal.

To resist temptation to use TC for an undiagnosed rash; this makes the possibility of correct diagnosis even bleaker in the future.