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Introduction
TCS, introduced into dermatologic therapy in1952, (hydrocortisone by Sulzberger andWitten)
Most commonly used drugs in dermatologicalpractice
Play a vital role in dermatologists’ armory fortreatment of a large number of inflammatorydisorders
However, they can act as double-edged swordif misused
Need judicious handling by both prescriber aswell as patient
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Chief seduction of TC lies in rapidity ofsymptomatic relief in almost any dermatosis
This often prompts busy physician to reversenatural order of diagnosis followed by treatment
Even incorrect use, for instance in infectiousdermatoses, produces an initial improvement insymptoms
Apart from their anti-inflammatory effect, TC alsohave potent antipruritic, vasoconstrictive,antiproliferative, melanopenic, sex-hormonelikeand immunosuppressive effects on skin
All these can lead to significant local adverseeffects if TCs are used indiscriminately
IJDVL | March-April 2011 | Vol 77 | Issue 2
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TCS are misused both by prescribing doctor andpatient 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 usedas fairness cream
Sequence events that lead to steroid abuse is asfollows- Doctor will prescribe moderately potent steroid to get
benefit and avoid side effects of potent steroid, for somedermatosis
Impressed by response, patient continues to use it andoften refer to friends also
Effect of steroid reduces due to tachyphylaxis andpatient is forced to use potent steroid and cyclecontinues
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Brand names and composition of topical
corticosteroid-containing products
IJDVL | March-April 2011 | Vol 77 | Issue 2
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Source and reason for using preparation in 140
patients who misused topical corticosteroids
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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
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GUIDELINES FOR SELECTION OF AN APPROPRIATE TCS
Low to medium potency agents generally are used to treat
acute inflammatory skin lesions of face and intertriginousareas,
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 forpalms 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 infantsand elderly because of concerns about an increasedsurface-to-weight ratio and increased skin fragility,
respectively.
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Penetration varies between eyelid and plantarskin about 300-fold
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HUMAN MODELS OF TESTING CORTICOSTEROID
EFFICACY AND STRENGTH
Vasoconstriction test
After applying a defined quantity (eg, 5 mg) of Cs preparation toa defined skin area, vasoconstriction is assessed visually or bymeans 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 andtreated 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 topicalcorticosteroid is evaluated at 12 hours
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ADVERSE EFFECTS OF TOPICAL
CORTICOSTEROIDS
Under normal conditions, up to 99% of appliedtopical corticosteroid is removed , only 1% is
therapeutically active Local adverse events of corticosteroid use are far
more prevalent than systemic reactions
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Adverse effects of TCS
Atrophic changes
Steroid atrophy
Telangiectasia
Striae
Purpura
Stellate pseudoscars Ulceration
Easy bruising
Infections
Masked microbial infections(tinea incognito)
Aggravation of cutaneouscandidiasis, herpes or demodex
Reactivation of Kaposi sarcoma
Granuloma gluteale infantum
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)
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Atrophy
Reflected by increased transparency and shininessof skin, as well as appearance of striae
Atrophy recognized as M/c adverse effect of TCS
Dermal atrophy is probably caused by decreasedfibroblast growth and reduced synthesis of collagenand acid mucopolysaccharides
Intertriginous areas are particularly susceptible,
probably owing to thinner skin, increased moisture,elevated temperature, and partial occlusionprovided by skin in these sites
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Telangiectasia
CS stimulate human dermal microvascular
endothelial cells, leading to the occurrence oftelangiectasia.
Characterized by an abnormal dilatation of capillaryvessels and arterioles
Striae
Visible linear scars, form in areas of dermal damage,presumably during mechanical stress
Develop with an initial inflammation and edema ofdermis, followed by deposition of dermal collagenalong lines of mechanical stress
Histologically, represent scar tissue and therefore,once developed, are permanent.
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Purpura, stellate pseudoscars, and
ulcerations
Arise when severe steroid induced dermal atrophyand loss of intercellular substance occur, causingblood vessels to lose their surrounding dermal matrix.
Fragility of dermal vessels leads to purpuric,irregularly shaped, hypopigmented, depressed scars
stellate pseudoscars most frequently develop overextremities, mostly on severely atrophic,
telangiectatic purpuric skin True ulceration from continued abuse of
corticosteroids has also been reported
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A, Steroid atrophy on dorsum of hand
with hyperpigmentation as a consequence
of easy bruising caused by rarefaction of
connective tissue. Stellate pseudoscarsand increased wrinkling are also apparent
B, Thickened lichenified skin, severe
epidermal atrophy, and erythema after
inappropriate use of high-potency
corticosteroids on eyelids.
Striae
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Steroid rosacea
Dermatoses of the face are usually steroid-sensitive anddo not require potent formulations
Classical history of steroid rosacea begins in a middleaged woman with intermittent papules and pustulesthat are initially controlled with steroids of low potency
Subsequently lesions may reappear and promptcontinued use of greater- potency topical corticosteroid
Hypertrichosis
Promote growth of vellus hair by means of an unknownmechanism
Darker hairs may persist for months after withdrawal ofsteroids
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(a) Marked atrophy and telangiectasia, (b) Severe exacerbation of acne with crustedand nodular lesions, (c) Tinea incognito after prolonged application of a super-potentTCs, (d) TCs-induced hypertrichosis, IJDVL | March-April 2011 | Vol 77 | Issue 2
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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
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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).
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Perioral dermatitis
A facial eruption, composed offollicular papules and pustuleson an erythematousbackground
Begin in a perioral distribution,
with prominent sparing of skinadjacent to vermilion border
Most frequently observed inyoung women,may be seen inmen and children
Caused by long-term use ofpotent 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
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(e) hypopigmentation: sparing of the periorbital area (f) topical steroid-dependentface" 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 aftertopical use is quitecommon
• Steroids probablyinterfere withsynthesis of melaninby smallermelanocytes, leadingto patchy areas of
hypopigmentation• Generally reversible
upondiscontinuation
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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.
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Aggravation of cutaneous infections
Common and often occur early in therapy
P. versicolor, onychomycosis, dermatophytosis, anddisseminated cutaneous Alternaria infection
Tinea incognito Marked tinea infections, transformed into unrecognizable cutaneous
eruptions
Prolongation or mitigation of herpes simplex, molluscumcontagiosum, 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
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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 delayedbarrier recovery (ie, increased transepidermal water loss)
May theoretically worsen barrier impairment in atopicdermatitis and psoriasis
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Contact sensitization to TCS
Generally rare, 0.2% and 6%.
Nonfluorinated corticosteroids (eg, hydrocortisone,hydrocortisone17-butyrate, and budesonide) result in ahigher prevalence of contact allergy
Binding to amino acid arginine as part of certain proteins
seems to be a prerequisite for allergic reactions tocorticosteroids
A classification scheme based on structural relation ofsteroid molecule has been devised for cross-reactivity
Representative agents hydrocortisone (group A),triamcinolone acetonide (group B), betamethasone (groupC), and hydrocortisone butyrate (group D), is useful forclinical tests of contact allergy
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Rare systemic adverse events of TCS
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Optimizing the use of TCS
To prescribe for appropriate dermatoses.
To use appropriate potency and strength of TC to achievedisease control.
To maintain with a less potent preparation or reducefrequency of application after satisfactory response.
To taper off treatment upon complete remission of skindiseases.
To be extra careful when prescribing topical steroid overcertain locations (e.g. scrotum, face, and flexures).
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Optimizing the use of TCS
To be especially considerate when prescribing to elderlyand children.
To be aware of adverse effects and act immediately tocounteract them.
To avoid home-made dilutions of TC and prescribing TC incombination with antimicrobial and antifungal.
To resist temptation to use TC for an undiagnosed rash; thismakes possibility of correct diagnosis even bleaker in future
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