Intervention text

To ensure proper use and monitoring of Topical Corticosteroids side effects

1. Know the potency of topical corticosteroid that your patient is using by downloading a potency chart and identifying the potency your patient is using. 

2. Review Summary 14-18 of the Atopic dermatitis: A practice parameter update 2012  Atopic dermatitis: A practice parameter update 2012 

Summary Statement 14: If AD is not controlled by moisturizers alone, then the clinician should recommend a topical corticosteroid.(A)
Summary Statement 15: Low-potency corticosteroids are recommended for maintenance therapy, whereas intermediate and high-potency corticosteroids should be used for the treatment of clinical exacerbation over short periods of time. (A)
Summary Statement 16: Clinicians should not prescribe potent fluorinated corticosteroids for use on the face, eyelids, genitalia, and intertriginous areas or in young infants. (D)
Summary Statement 17: Clinicians should recommend ultrahigh-potency corticosteroids only for very short periods (1-2 weeks) and in nonfacial nonskinfold areas. (D)
Summary Statement 18: When prescribing topical steroids, clinicians should remember that the degree of corticosteroid absorption through the skin and hence the potential for systemic adverse effects are directly dependent on the surface area of the skin involved, thickness of the skin, the use of occlusive dressing, and the potency of the corticosteroid preparation.(D)

Corticosteroids are effective medications for the treatment of AD. However, patients should be carefully instructed in their use to avoid potential adverse effects. Certain areas, including the mucous membranes (lips), genitalia, eyelids, face, and intertriginous areas, have increased potential for transepidermal corticosteroid penetration, and for this reason, potent fluorinated corticosteroids should be avoided in these areas. A low-potency corticosteroid preparation is generally recommended for these areas. For patients with very severe AD, clinicians might consider a few days of higher-potency topical steroids but should warn patients about local side effects and prescribe a limited amount of the topical steroid. Cheilitis can be problematic in patients with AD, and a few days of 1% or 2.5% hydrocortisone ointment (eg, CortiBalm; Dr. Dan’s Lip Balms, Milan, Ind) followed by frequent use of moisturizers is usually effective.
Patients should be instructed to apply topical corticosteroids to skin lesions and to use moisturizers over uninvolved skin. There are 7 classes of topical corticosteroids ranked according to their potency based on vasoconstrictor assays. Some of the commonly used ones are listed in Table E1. Group I includes the super-potent topical corticosteroids with the greatest potential for adverse effects, both localized and systemic. Group VII includes the least potent topical corticosteroids and, as a group, has the least potential for adverse effects. More potent topical corticosteroids can be used for several days in non facial non skin fold areas to treat acute rashes. Patients should then be instructed to reduce the potency of topical corticosteroids applied to the skin. Because of their potential adverse effects, the ultra high potency corticosteroids should be used for only very short periods of time (1-2 weeks) and not on facial or skinfold areas. The high potency corticosteroids should only be used for short periods of time (up to 3 weeks) for clinical exacerbations. Intermediate potency corticosteroids, such as 0.1% triamcinolone, can be used for longer periods of time to treat chronic AD involving the trunk and extremities. Corticosteroids in gel formulations can contain a propylene glycol base that can irritating to the skin, in addition to promoting dryness, limiting their use to the scalp and beard areas. In general, compared with topical creams, ointments have enhanced topical potency, although some modern vehicles might offset this tendency. 

Adverse effects from topical corticosteroids are directly related to the potency ranking of the compound and the duration of use. It is incumbent on the clinician to balance the need for therapeutic potency with the potential for adverse effects. Adverse effects from topical corticosteroids can be divided into local and systemic adverse effects. Systemic adverse effects, which occur rarely, include suppression of the hypothalamic-pituitary-adrenal axis. Local adverse effects include the development of striae and atrophy of the skin, perioral dermatitis, rosacea, and allergic contact dermatitis (caused by the vehicle or steroid itself). Systemic adverse effects are related to the potency of the topical corticosteroid, the site of application, the occlusiveness of the preparation, the percentage of the body covered, and the length of use. The potential for prolonged use of potent topical corticosteroids to cause adrenal suppression is greatest in small children and infants.64,65 Two newer topical corticosteroids (fluticasone propionate and mometasone furoate) appear to have less systemic absorption and an efficacy profile that allows them to be used once as opposed to twice daily.66,67 Furthermore, several trials support that once control of AD is achieved with a daily regimen of topical corticosteroid, long-term control can be maintained with twice-weekly applications of topical fluticasone propionate to areas that have healed but are prone to eczema.68,69,70

3. Review JEADV 2012, 26, 1045–1060 Journal of the European Academy of Dermatology and Venereology ª 2012 European Academy of Dermatology and Venereology  European Guidelines Part 1