Number 31

December 1994

TOPICAL CORTICOSTEROIDS

For initial control of inflammation use strong topical corticosteroids.

For maintenance treatment reduce strength or use strong topical
corticosteroids intermittently.

For areas susceptible to steroid damage, e.g. face, around eyes, flexures,
use mild to moderate topical corticosteroids.

Children are at greater risk of systemic side effects. Use mild to
moderate topical corticosteroids, or if unresponsive use strong topical
corticosteroids intermittently to severe areas.

Mometasone furoate shows some dissociation of strength and side
effects, fewer local side effects and decreased systemic effects compared
with topical corticosteroids of similar strength.

Drug Formulation

Mild
Hydrocortisone 1%

Moderately Strong
Aclometasone dipropionate 0.05% Logoderm C, O
Clobetasone butyrate 0.05% Eumovate C, O
Triamcinolone 0.02% + 0.05% Aristocort C, O

Strong
Betamethasone valerate 0.1% Betnovate C, O, L, S
Betamethasone dipropionate 0.05% Diprosone C, O, S
Hydrocortisone-17-butyrate 0.1% Locoid C, LC, L, O, S
Diflucortolone valerate 0.1% Nerisone C, FO, O
Fluocinolone acetonide 0.025% Synalar C, O, G
Mometasone furoate 0.1% Elocon C, O, L

Very Strong
Clobetasol propionate 0.05% Dermovate C, O, S
Betamethasone dipropionate 0.05% Diprolene C, O
in propylene glycol base

C (Cream) O (Ointment) L (Lotion) S (Scalp lotion) G (Gel) LC (Lipocream) FO (Fatty
ointment)


Published by The National Preferred Medicines Centre Incorporated
Level 30, Grand Plimmer Tower, PO Box 10-545, Wellington, NZ
Phone +64-4-470 7735, Fax +64-4-471 4185, www.premec.org.nz

When choosing a topical corticosteroid (TC)
consider the disease type, site, severity, extent and
age of the patient. Choose a TC of appropriate
strength in the appropriate base and give
instructions as to the frequency and mode of
application. Calculate the appropriate amount to be
dispensed. There should be a longterm treatment
plan.

Strength
TCs can be divided into 4 groups according to
strength; mild, moderately strong, strong, very
trong. (see Table). s

NB Strength refers to the maximum effect achievable with a
given preparation. Potency is often erroneously used when
strength is meant. Potency merely refers to the dose or
oncentration required to achieve a given effect. c

In general it is best to use a strong or very strong
TC to gain control of inflammation and to reduce
either the strength and/or frequency of application
of the TC once the inflammation begins to settle.
This approach minimises the risk of side effects and
tachyphylaxis. Various schedules of intermittent
corticosteroid therapy have been proposed for
maintenance treatment, e.g. in pulse dosing
treatment for psoriasis - the patient uses a very
strong TC at three 12 hourly intervals on a weekly
basis. When strong TCs are used intermittently, an
emollient should be used more frequently as a
substitute.

Skin site
Use low strength TC on areas of high absorption,
e.g. face, flexures, scrotum. High strength TC may
be needed on areas of decreased absorption, e.g.
palms and soles.

Hydration
Hydration increases absorption 4-5 fold, hence
opical TCs work best if applied after a bath. t

Occlusion
This maintains hydration of the skin and increases
absorption of TCs. Occlusion can be achieved by
application of plastic wrap or gloves (increases
absorption 10-fold), by bio-occlusive dressings (e.g.
Duoderm), and occurs naturally in skin folds and
nder the nappy of infants. u

Children
Children are at greater risk for systemic adverse
effects of TCs because of relatively greater
absorption and higher blood concentrations. They
have a greater surface area to body weight ratio than
adults. There may also be increased penetration of
TCs into the skin of very young children.
Therefore, low strength preparations should be used
when possible. Strong TCs can be used for short
periods to severe areas if not adequately controlled.
Try to alternate strong Tcs with the use of
emollients or low strength Tcs.

Frequency of Application
Once to twice daily is as effective as 3-6 times
daily. Start with twice daily to gain control and
later reduce to once daily. Once daily use is
recommended for mometasone furoate (Elocon).

Vehicle
Use ointments for dry skin. Creams are preferred
for face, flexures and weeping rashes.
Hydroalcoholic solutions or gels are best for the
scalp

Amount prescribed
12 g is the minimum amount required for whole
body application although some authors quote
figures of 20-30 g.

Rule of hand: 4 hands = 2FTU = 1 g
One fingertip unit (FTU)
= amount one would express from a
tube with a 5mm diameter nozzle
applied from the distal skin crease
to the tip of the index finger.
Hand area = area of one side of flat closed hand
= 0.75% of body surface area
One hand area requires 0.25g ointment which
= 0.5 FTU

Side effects
a) Local
Atrophy -striae, telangiectasia, purpura
Masking or promoting undetected infection, e.g.
fungi, impetigo
Perioral dermatitis (steroid rosacea)
Allergic contact dermatitis to TC or base

b) Systemic
Systemic absorption may lead to inhibition of
pituitary adreanl axis. Severe medical problems
are rare. Growth suppressionwith longterm use
of strong Tcs in children may occur.
Cataract and glaucoma may occur if strong TCs
used around the eye

For most TCs, the risk of adverse effects is
proportional to efficacy. New corticosteroids with
a better benefit/risk ratio may be available in the
future. Mometaosne furoate is a step in this
direction. It is a strong TC which has a lower risk
of systemic and local adverse effects compared with
TCs of equal strength.

References
1) Gianotti B. Drugs 1988; 38 (Suppl 5): 9-14.
2) Mori M et al. Drug Safety 1994; 10 (5): 406-412.
3) Lang CC et al. Arch Dermatol 1992; 128: 1129-1130.

The information contained in this bulletin is issued on the understanding that
it is the best available from the resources at our disposal at the time of issue.