Topical Steroid TherapyTopical Steroid Therapy

Val AndersonVal Anderson

Dermatology Specialist NurseDermatology Specialist Nurse

South Gloucestershire South Gloucestershire Community Health ServicesCommunity Health Services

What are steroids?What are steroids?

• Essentially hormonesEssentially hormones

• Glucocorticoids/ mineralcorticoidsGlucocorticoids/ mineralcorticoids

• Naturally formed in the adrenal Naturally formed in the adrenal cortexcortex

• Natural glucocorticoids maintain Natural glucocorticoids maintain normal blood sugar and assist the normal blood sugar and assist the body to recover in times of stress.body to recover in times of stress.

Why Topical Steroids ?Why Topical Steroids ?

• To gain control of signs and To gain control of signs and symptoms of inflammatory skin symptoms of inflammatory skin diseasedisease

• Achieve maximum efficacy with Achieve maximum efficacy with minimal side effects.minimal side effects.

Action of Topical SteroidsAction of Topical Steroids

• Anti-inflammatoryAnti-inflammatory

• ImmunosuppressiveImmunosuppressive

• VasoconstrictiveVasoconstrictive

• Anti-mitotic – decrease proliferationAnti-mitotic – decrease proliferation

• Readily penetrate the dermisReadily penetrate the dermis

“ “Reduce inflammation and make the skin less sore and itchyReduce inflammation and make the skin less sore and itchy””

Steroid PhobiaSteroid Phobia

• Present in health care professionals, Present in health care professionals, patients and carers.patients and carers.

• A reluctance to use prescribed topical A reluctance to use prescribed topical steroids due to perceived side effectssteroids due to perceived side effects

• Reassurance is essential to gain full Reassurance is essential to gain full concordance with treatment.concordance with treatment.

REMEMBER: Appropriate topical steroid REMEMBER: Appropriate topical steroid use limits potential side effects almost use limits potential side effects almost entirely.entirely.

Potential side effectsPotential side effects

CutaneousCutaneousThinning / Atrophy Thinning / Atrophy HypopigmentationHypopigmentationStriaeStriaeTelangietasiaTelangietasiaTachyphylaxis, Tachyphylaxis, Infections, Infections, Perioral dermatitis,Perioral dermatitis,Contact dermatitis, Contact dermatitis, Hirsutism, Hirsutism, Monomorphic acne or rosaceaMonomorphic acne or rosacea

N.BN.BEpidermal thinning does occur within 1-3 weeks of tx with potent Epidermal thinning does occur within 1-3 weeks of tx with potent or or

very potent steroids normal skin but reverses within 4 weeks of very potent steroids normal skin but reverses within 4 weeks of stoppingstopping

Potential Side Effects : Potential Side Effects : systemicsystemic• These are RARE and ALWAYS AVOIDABLEThese are RARE and ALWAYS AVOIDABLE

• Due to systemic absorption of the steroidDue to systemic absorption of the steroid

Adverse effects : Adverse effects : systemicallysystemically• OsteoporosisOsteoporosis

• Muscle atrophyMuscle atrophy

• Cushings SyndromeCushings Syndrome

• Inhibition of growth (children)Inhibition of growth (children)

• CataractsCataracts

• Masking of infectionMasking of infection

• HypoglycaemiaHypoglycaemia

Which steroid?- factors to Which steroid?- factors to considerconsider

• Age /potency – adult, adolescent or childAge /potency – adult, adolescent or child

• Site – absorption increased at certain Site – absorption increased at certain sitessites

• Extent- localised or generalisedExtent- localised or generalised

• Base- creams or ointments? Base- creams or ointments?

• Method- frequency of application / Method- frequency of application / occlusionocclusion

• Experience of use - dexterityExperience of use - dexterity

Steroid potenciesSteroid potencies

•Group I. Mild e.g. Hydrocortisone 1% OTC (over the counter)Group I. Mild e.g. Hydrocortisone 1% OTC (over the counter)

•Group II. Mod (1 X OTC)Group II. Mod (1 X OTC)

•Group III. Potent Group III. Potent prescription only prescription only

•Group IV. Very potent Group IV. Very potent prescription only prescription only

Relative potencies compared to Hydrocortisone 1% (Grp Relative potencies compared to Hydrocortisone 1% (Grp I) I)

•Group 2 - 2.5 x strongerGroup 2 - 2.5 x stronger

•Group 3 - 10 x strongerGroup 3 - 10 x stronger

•Group 4 - 50 x strongerGroup 4 - 50 x stronger

Steroid ladderSteroid ladderVERY POTENT VERY POTENT DermovateDermovate Nerisone ForteNerisone Forte

POTENTPOTENT SynalarSynalar FucibetFucibet DiprosalicDiprosalic BetnovateBetnovate EloconElocon LocoidLocoid

MODERATELY MODERATELY POTENTPOTENT

EumovateEumovate HaelanHaelan TrimovateTrimovate Calmurid HCCalmurid HC Betnovate RDBetnovate RD Synalar 1 in 4Synalar 1 in 4

MILDMILD Hydrocortisone Hydrocortisone

0.5%,1.0% & 0.5%,1.0% & 2.5%2.5%

Fucidin HFucidin H Alphosyl HCAlphosyl HC Synalar 1 in 10Synalar 1 in 10

Steroid applicationSteroid application

•Reassure - explain rationale for use and benefitsReassure - explain rationale for use and benefits

•Early use - to control exacerbationsEarly use - to control exacerbations

•Therapeutic dose - < prolongs flare and subsequent Therapeutic dose - < prolongs flare and subsequent controlcontrol

•Demonstrate - light smear, F.T.U (finger tip unit)Demonstrate - light smear, F.T.U (finger tip unit)

Weekly Quantities of steroid Weekly Quantities of steroid Adult using b.d applicationsAdult using b.d applications

Creams and OintmentsCreams and Ointments• face & neck…………………… 15 - 30gface & neck…………………… 15 - 30g• both hands…………………… 15 - 30gboth hands…………………… 15 - 30g• scalp………………………….. 15 - 30gscalp………………………….. 15 - 30g• both arms…………………….. 30 - 60gboth arms…………………….. 30 - 60g• both legs……………………… 100gboth legs……………………… 100g• trunk…………………………... 100gtrunk…………………………... 100g• groins & genitalia……………. 15 - 30ggroins & genitalia……………. 15 - 30g

BNF March 2006BNF March 2006

Summary of NICE Summary of NICE GuidelinesGuidelines

• No statistical difference between No statistical difference between once and twice daily steroid once and twice daily steroid applicaton frequency on efficacy.applicaton frequency on efficacy.

• Application 10-14 days and consider Application 10-14 days and consider steroid holidaysteroid holiday

• Improve patient and carer educationImprove patient and carer education

Steroid WorkshopSteroid Workshop

•Practice finger tip unit measurementsPractice finger tip unit measurements

•Discuss photos and case studiesDiscuss photos and case studies

Case Study 1Case Study 1

• 6 month old baby with history of eczema 6 month old baby with history of eczema since 4 months old.since 4 months old.

• Tried emollients and has been given Tried emollients and has been given topical steroids by GP 2 weeks ago.topical steroids by GP 2 weeks ago.

• O/E moderate eczema present on facial O/E moderate eczema present on facial cheeks. Excoriations present and baby cheeks. Excoriations present and baby waking at night.waking at night.

• Not improved since prescription for topical Not improved since prescription for topical steroid given.steroid given.

What issues related to What issues related to topical steroid use would topical steroid use would

you consider during you consider during assessment and treatment assessment and treatment

decisions for this child ?decisions for this child ?

Case Study 2Case Study 2

• 14 year old boy14 year old boy

• History of eczema since 2 years old.History of eczema since 2 years old.

• O/E has moderate levels of eczema in O/E has moderate levels of eczema in arm flexures with some weeping.arm flexures with some weeping.

• Prescribed hydrocortisone 1% Prescribed hydrocortisone 1% ointment by GP 3 weeks ago- nil ointment by GP 3 weeks ago- nil improvement.improvement.

• Arms now becoming sore.Arms now becoming sore.

What issues related to What issues related to topical steroid use would topical steroid use would

you consider during you consider during assessment and treatment assessment and treatment

decisions for this child ?decisions for this child ?

Any Questions ?Any Questions ?

I have one for youI have one for you

What will you do What will you do differently tomorrow?differently tomorrow?