Topical Corticosteroids: 10 Must-Know Facts

Knowing these facts can help keep topical corticosteroid use safe and effective.

For patients with all kinds of skin problems, topical corticosteroids—prescription and OTC strength—are often soothing, as well as generally safe and effective.¹ Let’s review 10 facts about these topicals.

1. Skin disorders prompt many physician visits. A 2013 Mayo Clinic study that included more than 140,000 patients revealed that skin disorders are the most common nonacute reason Americans seek health care.² Topical corticosteroids, available since the 1950s, are the most prescribed dermatologic drugs and the mainstay of treatment for many conditions.^3,4

2. Topical steroids are costly, even in generic form. Prices have risen over the past few years as generic manufacturers have consolidated (Table 1).⁵ Manufacturers invest $500,000 to $1.5 million to bring generic topical formulations to market, and if the FDA requires bioequivalence studies, the cost rises to $4 to $6 million. Generic topical steroids are still less costly than brand products.⁶ Due to the high cost, insurance companies monitor the estimated days’ supply closely to limit refills, and pharmacists must counsel patients to avoid waste. If patients need products for the long term and the prescription requires a large dose, using large sizes rather than dispensing multiple small tubes saves money.⁴

3. Potency matters. Topical steroids’ potencies reflect molecular modifications (Online Table 2^7,8). For example, adding a 5-carbon valerate chain to the 17-hydroxyl position of betamethasone results in a compound more than 300 times more potent.9 Increasing potency also increases the risk of side effects (discussed below).

4. The delivery vehicle matters. The drug delivery vehicle—ointment, cream, lotion, or gel—can change the drug’s potency.

Ointments’ occlusive effects make them ideal for dry, thick, or hyperkeratotic skin, but too greasy for hairy areas. Patients oftendislike their feel and become nonadherent.⁴

Creams’ vanishing nature increases cosmetic appeal but decreases steroid effectiveness. On acutely exudative lesions, creams can speed drying.^4,10

Alcohol- or lubricant-based lotions feel better on hairy areas. Patients with acute exudative lesions prefer alcohol-based lotions, but individuals with chronic dry scalp lesions prefer lubricant-based lotions.^4,11

Gels—liquids that behave like solids—have drying effects due to their water and alcohol content; they are good for wet, oozing rashes such as those caused by poison oak or ivy.⁴

5. Not all skin is equal. Using topical corticosteroids on a patient’s face is tricky. Steroids can cause atrophy due to collagen loss, opportunistic infections, purpura, periorifical dermatitis, and rosacea exacerbation. Areas around the eyes and eyelids are especially thin and more vulnerable. In the elderly, progressive age-related skin changes elevate risk. Using the more potent topical corticosteroids increases the risk for adverse events, and so does using occlusion.^4,12,13

6. More is not better. Most products are FDA approved for application once or twice daily. Patients often think more is better, so pharmacists need to warn against this practice, especially with high-potency products. In chronic cases, physicians sometimes prescribe topical pulse therapy. This therapy generally requires the patient to apply high-potency product only on 2 consecutive days a week to minimize side effects; the remainder of the week, the patient uses a low-potency product.^4,14,15

7. Duration of use varies. Side effects are rare when low- to high-potency topical steroids are used for 3 months or less, unless they are applied to intertrignous areas (areas where skin may rub together), on the face and neck, and under occlusive dressings.⁸ For ultra—high-potency topical steroids, if use exceeds 3 continuous weeks, tolerance and tachyphylaxis (decreased response) can develop, so prescribers should taper patients off these topicals. If patients need longer treatments, prescribers can use topical pulse therapy after a 1-week steroid-free period. This therapy reduces rebound effects.⁸

8. Side effects happen. Patients rarely expect side effects (Table 31,4,13,15) from topicals, but side effects are possible and even likely if these products are used incorrectly.

9. Prescribers may need guidance. Prescribers sometimes inadvertently allow excessive-potency topical steroid use, long duration of use, and topical steroid use on the face and neck. Community pharmacists are ideally placed to monitor response and provide advice about best practices.¹

10. Patients need clear instructions. Applying topical drugs can be cumbersome. Patients may misunderstand instructions from prescribers.¹⁶ Topical corticosteroids present a conundrum: too little hampers response, and too much increases the risk of adverse effects.¹⁷

Pharmacists must reinforce other clinicians’ instructions and include additional reminders, including these points^1,4:

• Describe what the topical is—a steroid product—and the potential benefit of using it correctly.
• Identify a realistic goal (eg, “Continue until redness and itching are gone”) and when to call the prescriber if no improvement occurs.
• Identify the duration of treatment and when to retreat.
• Show how to measure and apply the product, using the fingertip unit method or an included measuring device.
• Explain that if a patient needs a refill, 15 g will cover an area the size of 1 hand 3 times a day for 2 weeks, so patients will need more if they have large areas to cover.
• Describe how to taper the therapy potency up or down, if needed.
• Explain possible side effects: what to look for, when to stop treatment, etc.

Closing Thought

Patients need to be reminded not to share their topical steroids with others, and that these products should not be used as bleaching agents.^1,4,14 This is especially true with high- to ultra-high-potency products.

Virginia Bartok is a retired pharmacist who lives in eastern Connecticut and comes out of retirement to write. Her primary practice was indigent care.

References

• Bewley A. Expert consensus: time for a change in the way we advise our patients to use topical corticosteroids. Br J Dermatol. 2008;158:917-920.
• Sauver J, Warner D, Yaw B. Why patients visit their doctors: assessing the most prevalent conditions in a defined American population. Mayo Clinic Proc. 2013;881:56-67.
• Rathod SS, Motghare VM, Deshmukh VS, Deshpande RP, Bhamare CG, Patil JR. Prescribing practices of topical corticosteroids in the outpatient dermatology department of a rural tertiary care teaching hospital. Indian J Dermatol. 2013;58:342-345.
• Crosby J, Morales R. A penny pincher’s guide to topical corticosteroids. Consultant Live website. www.consultantlive.com/articles/%E2%80%9Ctear-out%E2%80%9D-sheets-quick-reference. Accessed April 19, 2014.
• Latest acquisitions fuel consolidation trend. Chain Drug Rev. 2012;34:69.
• Drug approval and the case of corticosteroids. Bryn Mawr Communications website. http://bmctoday.net/vehiclesmatter/2010/03/article.asp?f=drug-approval-and-the-case-of-corticosteroids. Accessed April 20, 2014.
• Epocrates. Dermatologic drugs. Athenahealth, Inc, website. https://online.epocrates.com. Accessed April 18, 2014.
• Corticosteroids, topical: drug facts and comparisons. Facts & Comparisons [online database]. St. Louis, MO: Wolters Kluwer Health, Inc; 2014. Accessed April 20, 2014.
• Katzung B, Masters S, Trevor A, et al. Chapter 61: dermatologic pharmacology. Basic and Clinical Pharmacology. 11th ed. New York: McGraw Hill; 2009.
• Ference J, Last A. Choosing topical corticosteroids. Am Fam Physician. 2009;79:135-140.
• Tawade Y. Topical corticosteroids in pediatric age group. Pediatric Oncall website. www.pediatriconcall.com/fordoctor/Conference_abstracts/report.aspx?reportid=214. Accessed April 20, 2014.
• Savage R, Rademaker M. Topical corticosteroids: face facts. Medsafe website. www.medsafe.govt.nz/profs/PUarticles/steroidface.htm. Accessed April 20, 2014.
• Shen S, Kelly R. Pharmacotherapy for skin disorders in older people. Austral J Pharm. 2012;10:84-86.
• Nnoruka E, Okoye O. Topical steroid abuse: its use as a depigmenting agent. J Natl Med Assoc. 2006;98:934-939.
• Serup J, Lindblad A, Maroti M, et al. To follow or not to follow dermatological treatment: a review of the literature. Acta Derm Venereol. 2006;86:193-197.
• Thomas K, Armstrong S, Avery A, et al. Randomised controlled trial of short bursts of a potent topical corticosteroid versus prolonged use of a mild preparation for children with mild or moderate atopic eczema. BMJ. 2002;324:768.
• Mirshad P, Khan A, Rahiman F, et al. Prescription audit of corticosteroid usage in the department of dermatology at a tertiary care teaching hospital. Int J Basic Clin Pharmacol. 2013;2:411-413.