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Topical Steroids

»	When were corticosteroids discovered? When were they first used therapeutically?
»	Describe the basic steroid nucleus.
»	How is the potency of topical steroid medications determined?
»	How do topical steroids inhibit cutaneous inflammation?
»	How are topical corticosteroids classified as to potency?
»	How many topical steroid medications are available in the United States?
»	What are the differences between brand name and generic topical steroid products?
»	With so many products available, how do you decide which product to prescribe for your patient?
»	What specific directions should be provided when prescribing super-, high-, and midpotency topical steroids?
»	Why is the vehicle important when recommending a topical corticosteroid?
»	Are certain vehicles preferred for particular types of lesions or anatomic sites?
»	A patient has 5% total body surface area (TBSA) involvement. How much topical steroid should be prescribed for twice daily application for a 1-week-on and 1-week-off treatment cycle? The patient will return in 4 weeks for follow-up.
»	How should the FTU application technique be applied to children?
»	When are combination topical steroid and antiinfective products indicated?
»	What is tachyphylaxis and how can it be prevented?
»	What are the local cutaneous side effects of topical steroids?
»	What are the effects of topical steroids on the epidermis?
»	What are the effects of topical steroids on the dermis?
»	What are the systemic side effects of topical steroid therapy?
»	Are there topical steroid addicts?
»	What is periorificial dermatitis?
»	What is tinea incognito?
»	Can topical steroid medications cause contact dermatitis?
»	Mrs. Jones brings her 9-month-old infant with moderate atopic dermatitis to your office. What topical steroid do you prescribe?
»	A 40-year-old woman presents with a 5-year history of chronic dermatitis on her palms. Lesions are plaques with abundant scale. What topical steroid do you prescribe?
»	A 35-year-old woman with moderate psoriasis presents with scalp, facial, and body plaque lesions. What topical steroid do you prescribe?
»	Mrs. Smith brings her 6-month-old infant with a 2-week history of diaper dermatitis to your office. What topical steroid do you prescribe? Would you recommend any other topical therapy?
»	List some common mistakes that are made when prescribing a topical steroid.

What are the systemic side effects of topical steroid therapy?

The superpotent topical steroids are over a thousand times more potent than hydrocortisone. Infants and children are more at risk for systemic side effects because they have greater surface-to-body ratio than adults, and they may not be able to metabolize the steroid molecule efficiently.

Adults can show hypothalamic-pituitary-adrenal (HPA) axis suppression within 3 to 4 days by use of as little as 7.5 gm of superpotent topical steroid daily. However, it is rare to see clinical Cushing’s syndrome in an adult patient. Superpotent topical steroids are not recommended for children under age 12 (see Table 50-2).

Table 50-2. Topical Steroid Side Effects
	LOCAL CUTANEOUS SIDE EFFECTS	SYSTEMIC SIDE EFFECTS
	Acne vulgaris, acne rosacea, periorificial dermatitis Atypical presentation of skin diseases (i.e., tinea incognito) Burning, stinging, erythema, peeling Contact dermatitis Delayed wound healing Dermal atrophy with skin “dents/potholes” Epidermal atrophy with telangiectasia and purpura Exacerbation of psoriasis with rebound phenomenon Exacerbation of skin infections and infestations Folliculitis Granuloma gluteal Hirsutism Hypopigmentation Skin blanching Steroid addiction syndrome Striae Susceptibility to skin infections	Cushing’s syndrome Fluid retention Growth retardation, failure to thrive Hypothalamic-pituitary-adrenal (HPA) axis suppression Hypertension Increased blood sugar Ocular hypertension, glaucoma, cataracts