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This document discusses the misuse and overuse of topical corticosteroids (TCS). It notes that while TCS provide rapid relief for many skin conditions, they can also cause significant adverse effects if used indiscriminately or long-term. The document outlines several reasons for misuse, including recommendations from non-medical sources, sharing prescriptions, and easy over-the-counter availability. Prolonged use can lead to thinning of the skin, easy bruising, striae, infections masked by TCS use, rosacea-like rashes, and steroid addiction where patients feel they need continued use. The document provides guidance on appropriate TCS selection and potential local adverse effects of long-term
This document discusses the misuse and overuse of topical corticosteroids (TCS). It notes that while TCS provide rapid relief for many skin conditions, they can also cause significant adverse effects if used indiscriminately or long-term. The document outlines several reasons for misuse, including recommendations from non-medical sources, sharing prescriptions, and easy over-the-counter availability. Prolonged use can lead to thinning of the skin, easy bruising, striae, infections masked by TCS use, rosacea-like rashes, and steroid addiction where patients feel they need continued use. The document provides guidance on appropriate TCS selection and potential local adverse effects of long-term
This document discusses the misuse and overuse of topical corticosteroids (TCS). It notes that while TCS provide rapid relief for many skin conditions, they can also cause significant adverse effects if used indiscriminately or long-term. The document outlines several reasons for misuse, including recommendations from non-medical sources, sharing prescriptions, and easy over-the-counter availability. Prolonged use can lead to thinning of the skin, easy bruising, striae, infections masked by TCS use, rosacea-like rashes, and steroid addiction where patients feel they need continued use. The document provides guidance on appropriate TCS selection and potential local adverse effects of long-term
1952, (hydrocortisone by Sulzberger and Witten) Most commonly used drugs in dermatological practice Play a vital role in dermatologists armory for treatment of a large number of inflammatory disorders However, they can act as double-edged sword if misused Need judicious handling by both prescriber as well as patient Chief seduction of TC lies in rapidity of symptomatic relief in almost any dermatosis This often prompts busy physician to reverse natural order of diagnosis followed by treatment Even incorrect use, for instance in infectious dermatoses, produces an initial improvement in symptoms Apart from their anti-inflammatory effect, TC also have potent antipruritic, vasoconstrictive, antiproliferative, melanopenic, sex-hormonelike and immunosuppressive effects on skin All these can lead to significant local adverse effects if TCs are used indiscriminately
IJDVL | March-April 2011 | Vol 77 | Issue 2 TCS are misused both by prescribing doctor and patient themselves, as it gives instant relief to signs and symptoms Face is the commonest site of such misuse as its effect is cosmetically appreciable, most often used as fairness cream Sequence events that lead to steroid abuse is as follows- Doctor will prescribe moderately potent steroid to get benefit and avoid side effects of potent steroid, for some dermatosis Impressed by response, patient continues to use it and often refer to friends also Effect of steroid reduces due to tachyphylaxis and patient is forced to use potent steroid and cycle continues Nonmedical advisers Friends, neighbors, beauticians, barbers, etc. Telling use it as fairness/cosmetic creams, anti-acne, anti- fungal therapy and for skin eruptions Tendency to reuse old prescription for a recurrent or new rash Prescription sharing with relatives and friends on presumption that similar looking skin problems can be self-treated Easy availability, asking without a valid prescription at chemist shop To prescribe rationally, India has only a little over 6500 qualified dermatologists to cater to a population of over 1.2 billion
Brand names and composition of topical corticosteroid-containing products IJDVL | March-April 2011 | Vol 77 | Issue 2 Source and reason for using preparation in 140 patients who misused topical corticosteroids Effects and side-effects of TCs depend mainly on Thickness of skin Potency of TC Amount of absorption Factors affecting absorption of the drug Vehicle, site and frequency of application, duration of therapy, barrier function and condition of skin GUIDELINES FOR SELECTION OF AN APPROPRIATE TCS
Low to medium potency agents generally are used to treat acute inflammatory skin lesions of face and intertriginous areas, High potent agents are often required to treat chronic, hyperkeratotic, or lichenified lesions on palms and soles Applied once or twice daily Greater frequency of application may be necessary for palms or soles Every-other-day or week- end-only application may be effective in treatment of several chronic conditions Lower-potency agents are preferentially used in infants and elderly because of concerns about an increased surface-to-weight ratio and increased skin fragility, respectively. Penetration varies between eyelid and plantar skin about 300-fold
HUMAN MODELS OF TESTING CORTICOSTEROID EFFICACY AND STRENGTH Vasoconstriction test After applying a defined quantity (eg, 5 mg) of Cs preparation to a defined skin area, vasoconstriction is assessed visually or by means of infrared reflection photometry Ultraviolet erythema test TCS is applied 24 hours prior to UVA or UVB light exposure Erythema is induced by applying 3 fold MED 7 hr after UV exposure, extent of the erythema is scored and treated sites are compared with untreated ones Pyrexial erythema test Intracutaneous injection of a defined quantity of bacterial pyrogen (purified lipopolysaccharide of Salmonella abortus equiis) Local inflammation with and without application of topical corticosteroid is evaluated at 12 hours
ADVERSE EFFECTS OF TOPICAL CORTICOSTEROIDS
Under normal conditions, up to 99% of applied topical corticosteroid is removed , only 1% is therapeutically active Local adverse events of corticosteroid use are far more prevalent than systemic reactions Adverse effects of TCS
Ocular changes Ocular hypertension Glaucoma cataract Pharmacologic effects Steroid rebound, steroid addiction, tachyphylaxis Miscellaneous Steroid acne Perioral dermatitis Steroid rosacea Topical steroid-dependent face (TSDF) or red face syndrome Hirsutism Hyperpigmentation Hypopigmentation Photosensitization Rebound flare (psoriasis) Atrophy
Reflected by increased transparency and shininess of skin, as well as appearance of striae Atrophy recognized as M/c adverse effect of TCS Dermal atrophy is probably caused by decreased fibroblast growth and reduced synthesis of collagen and acid mucopolysaccharides Intertriginous areas are particularly susceptible, probably owing to thinner skin, increased moisture, elevated temperature, and partial occlusion provided by skin in these sites Telangiectasia CS stimulate human dermal microvascular endothelial cells, leading to the occurrence of telangiectasia. Characterized by an abnormal dilatation of capillary vessels and arterioles
Striae Visible linear scars, form in areas of dermal damage, presumably during mechanical stress Develop with an initial inflammation and edema of dermis, followed by deposition of dermal collagen along lines of mechanical stress Histologically, represent scar tissue and therefore, once developed, are permanent.
Purpura, stellate pseudoscars, and ulcerations
Arise when severe steroid induced dermal atrophy and loss of intercellular substance occur, causing blood vessels to lose their surrounding dermal matrix. Fragility of dermal vessels leads to purpuric, irregularly shaped, hypopigmented, depressed scars stellate pseudoscars most frequently develop over extremities, mostly on severely atrophic, telangiectatic purpuric skin True ulceration from continued abuse of corticosteroids has also been reported A, Steroid atrophy on dorsum of hand with hyperpigmentation as a consequence of easy bruising caused by rarefaction of connective tissue. Stellate pseudoscars and increased wrinkling are also apparent
B, Thickened lichenified skin, severe epidermal atrophy, and erythema after inappropriate use of high-potency corticosteroids on eyelids. Striae
Steroid rosacea Dermatoses of the face are usually steroid-sensitive and do not require potent formulations Classical history of steroid rosacea begins in a middle aged woman with intermittent papules and pustules that are initially controlled with steroids of low potency Subsequently lesions may reappear and prompt continued use of greater- potency topical corticosteroid
Hypertrichosis Promote growth of vellus hair by means of an unknown mechanism Darker hairs may persist for months after withdrawal of steroids
(a) Marked atrophy and telangiectasia, (b) Severe exacerbation of acne with crusted and nodular lesions, (c) Tinea incognito after prolonged application of a super-potent TCs, (d) TCs-induced hypertrichosis, IJDVL | March-April 2011 | Vol 77 | Issue 2 Acne
Can rapidly induce an acneiform eruption Attributed to degradation of follicular epithelium, resulting in extrusion of follicular content Initially lead to suppression of inflammatory papules and pustules Become more resistant upon recurrence, producing clinical picture of TCS induced acnelike lesion
Steroid abuse in a patient with atopic dermatitis showing generalized facial erythema, patchy hyperpigmentation on the forehead, increased atrophy, and wrinkles around eyes. This patient has continued treatment with stronger derivatives because of loss of effect (tachyphylaxis). Perioral dermatitis
A facial eruption, composed of follicular papules and pustules on an erythematous background Begin in a perioral distribution, with prominent sparing of skin adjacent to vermilion border Most frequently observed in young women,may be seen in men and children Caused by long-term use of potent CS on face A, Long-term inadvertent use of corticosteroids for treatment of perioral and cheek dermatitis. B, atrophic skin and white scarring, along with telangiectases (e) hypopigmentation: sparing of the periorbital area (f) topical steroid-dependent face" with bright erythema and monomorphic papules IJDVL | Mar-Apr 2011 | Vol 77 | Issue 2 Steroid addiction Patients continue treatment because of concerns that acne, rosacea, perioral dermatitis, or telangiectasia may flare up when treatment is withdrawn Some cases may also present as red burning skin syndrome Hypopigmentation
Decreased pigmentation after topical use is quite common Steroids probably interfere with synthesis of melanin by smaller melanocytes, leading to patchy areas of hypopigmentation Generally reversible upon discontinuation
Hypopigmentation and hyperpigmentation, easy bruising, telangiectases and atrophy on left forearm. Tinea incognito of leg Bruising, brownish discoloration of skin, and scarring in a 74- year-old woman with atopic dermatitis. Aggravation of cutaneous infections
Common and often occur early in therapy P. versicolor, onychomycosis, dermatophytosis, and disseminated cutaneous Alternaria infection Tinea incognito Marked tinea infections, transformed into unrecognizable cutaneous eruptions Prolongation or mitigation of herpes simplex, molluscum contagiosum, and scabies infection have been reported Granuloma gluteale infantum A persistent reddish-purple, granulomatous, papulonodular eruption that rarely occurs on buttocks, thighs, or inguinal fold in children Well-known consequence of diaper dermatitis that is being treated with corticosteroids Delayed wound healing keratinocytes (epidermal atrophy, delayed re- epithelialization) Fibroblasts (reduced collagen and ground substance, resulting in dermal atrophy and striae) Vascular connective tissue support (telangiectasia, purpura, easy bruising), and Impaired angiogenesis (delayed granulation tissue formation) Decreases in skin elasticity Epidermal barrier disturbance Decreased formation of lipid lamellar bodies and delayed barrier recovery (ie, increased transepidermal water loss) May theoretically worsen barrier impairment in atopic dermatitis and psoriasis
Contact sensitization to TCS Generally rare, 0.2% and 6%. Nonfluorinated corticosteroids (eg, hydrocortisone, hydrocortisone17-butyrate, and budesonide) result in a higher prevalence of contact allergy Binding to amino acid arginine as part of certain proteins seems to be a prerequisite for allergic reactions to corticosteroids A classification scheme based on structural relation of steroid molecule has been devised for cross-reactivity Representative agents hydrocortisone (group A), triamcinolone acetonide (group B), betamethasone (group C), and hydrocortisone butyrate (group D), is useful for clinical tests of contact allergy Rare systemic adverse events of TCS
Optimizing the use of TCS
To prescribe for 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 treatment upon complete remission of skin diseases.
To be extra careful when prescribing topical steroid over certain locations (e.g. scrotum, face, and flexures).
Optimizing the use of TCS
To be especially considerate when prescribing to elderly and children.
To be aware of 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 possibility of correct diagnosis even bleaker in future
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