Topical corticosteroids are powerful anti-inflammatory drugs that are classified based on their potency from mild to very potent. More potent corticosteroids are associated with greater risk of side effects. They work by preventing the formation of inflammatory molecules. Their absorption and effect can be enhanced by certain vehicle formulations, occlusion, damaged skin barriers, and other factors. Guidelines recommend restricting very potent corticosteroid use to small areas for short periods to reduce risk of side effects like skin atrophy.

1. Topical Corticosteroids
Quoted from original lecture of the same title of prof. dr
zienab abdelaziem, staff member of dermatology department
of Mansoura university – Egypt.

2. Introduction
• Topical corticosteroids are the most potent & effective anti-inflammatory
agents.
• Introductoin of TS started with hydrocortisone in 1952.
• After that further derivatives were produced with enhanced activity.
• The basic steroid moiety consisted of 21 carbon atoms.
• New synthetic TS were introduced by manipulation of both ring structure &
side chains of steroid skeleton.

4. Enhancement
• Addition of double bond between C1 &C2
• Fluorination of C9
• Esterefication at C17
• Addition of methyl group at C16
• Addition of various side chains e.g. valerate, acetonoides, butyrates &
propionate particularly to C21

5. why
• These manipulations enhance activity of TS which results in:
• Better penetration through the skin
• Slower degradation by enzymes
• Greater affinity to cytosol receptors

6. Classification (potency)
• TS are assessed for potency on basis of
1- Vasoconstrictor assay
2- Atrophogenicity assay
3- Clinical trials
• A combination of these is used to produce a grouping of steroids of roughly
equivalent potency
• Such groupings are clinically very helpful but can be regarded as only a rough guide

7. There are four categories of potency
• Mildly potent
• Moderately potent
• Potent
• Very potent

8. Mild TS
• Hydrocortisone base or acetate (Hydrocortisone, Alfacort)
• Methyl prednisolone ( Medrol)
• Aclometasone dipropionate ( Perderm)

9. Moderate TS
(2-25 times as potent as hydrocortisone)
• Flumethasone pivalate ( Locacortin )
• Hydrocortisone 17 butyrate ( Locoid)
• Clobetasone butyrate ( Eumovate )
• Triamcinolone acetonoide (Kenacort)

10. Potent TS
(100-150 times as potent as hydrocortisone )
• Betamethasone dipropionate (Diprosone)
• Betamethasone valerate (Betaderm,Betaval,Betnovate)
• Desoximetasone ( Esperson)
• Diflucortolone valerate 0.1%(Nerisone)
• Fluocinolone acetonoide (Synalar)
• Fluticasone propionate (Cutivate)
• Halometasone (Sicortin)
• Methylprednisolone aceponate (MPA)
• Mometasone furoate (Elocom)
• Prednicarbate (Dermatop)

11. Very potent TS
• (Up to 600 times as potent as hydrocortisone)
• Clobetasol propionate ( Dermovate, clobex shampoo)
• Diflucortolone valerate o.3% ( Nerisone forte )
• Halcinonide (Volog )
• Ulobetasol) Miracortin )

12. Percutaneous absorption of TS
• The effectiveness of TS is related to potency of the drug & its percutaneous
absorption
• The rate of penetration into the st. corneum is greater the more hydrophilic
the steroid
• On the other hand, penetration into the viable epidermis is greater with
lipophilic steroid
• Receptor binding by the cytoplasm is also greater with increasing lipid
solubility &clinical potency is related to high receptor binding

13. Percutaneous absorption of TS
• Receptor binding affinity is by:
1- Lipid soluble TS
2- Induction of double bond between C1 & C2
3- Flourination of C9
4- Esterification in C17

14. Percutaneous absorption of TS
• Other factors that enhance percutaneous absorption of TS:
1- Exposure to UVR
2- Inflamed skin e.g. atopic dermatitis & ED
3- Hydration of skin increase percutaneous absorption by 3-5 folds
4- Regional variation:TS is absorbed from scrotal skin (42 times) &check (13
times) more than forearm

15. Percutaneous absorption of TS
5- Vehicle: absorption of TS ointment is faster than TS cream
6- Occlusive dressing enhance percutaneous absorption by 10 folds
7- Age of patient: PA is increased in infant, small children & elderly

16. Mode of action
1- Anti-inflammatory
2- Antiproliferative
3- immunosuppressive

17. Anti-inflammatory Effect
• Prevent formation of prostaglandins & leukotriens
• V.C. Effect: due to inhibitory effect on prostaglandins, histamine &
vasoactive kinins
• Mast cell depletion
• decrease No. of epidermal langerhans cells
• decrease lymphoid cells & antibody production

18. Antiinflammatory effect of TS
NucleusCell
TS TS+Cytosol receptor
TS+Nuclear acceptor
DNA
mRNA
Ribosomes
Transcription
Translation
Protein synthesis
(Lipocortin)
Phospholipids
Phospholipase A
Arachidonic acid
Prostaglandins
Leukotreins
DNA

19. Antiproliferative Effect
• TS inhibit DNA synthesis & thus mitotic activity
• This occurs following potent TS
• Hydrocortisone is ineffective in this regard

20. Immunosuppressive effect
• Decrease Lymphoid cells division
• Block access of lymphokines to target cells

22. Side effects of TS
• These vary from local effects up to systemic manifestations due to
absorption of a potent TS or when it is applied on a large surface area.
• a direct relationship was found between unwanted effects & potency of TS
• Avoidance of these side effects can be achieved by relying on weaker TS or
by acquiring a clear appreciation of how, when& where to use the more
potent preparation

23. Side effects of TS
1. Epidermal effects:
a- Atrophy of skin which becomes thin, fragile & transparent
b- Melanocyte inhibition results in vitiligo like condition. This occurs more
likely with TS under occlusion or with intracutaneous steroid injection

24. Atrophy of skin

25. Side effects of TS
2. Dermal effects:
a- Reduction of collagen synthesis & ground substance with appearance of
striae.
2- From poor support of dermal vasculature it will be easily ruptured on
trauma leading to intradermal hemorrhage.

26. Striae and ID haemmorhage

27. Side effects of TS
3. Vascular effects:
• At first TS produce V.C. of superficial small vessels, followed by a phase of
rebound V.D. which in later stages is fixed
• So , telangiectasia, rosacea- like eruption & exacerbation of rosacea may
follow the use of & withdrawal of TS

28. Telangiectasia

29. Side effects of TS
4. Iatrogenic clinical syndromes:
• Tinea incognito
• Scabies incognito
• Infantile gluteal granuloma
 Results from TS on napkin area
 Charact. by oval dark brown or purplish nodules in napkin area
 An alteration of host response to candida under the influence of TS has been suggested
 After discontinuation of TS the nodules slowly disappear

30. Tinea incognito

31. Infantile gluteal granuloma

32. Side effects of TS
• Perioral dermatitis
Results from prolonged use of fluorinated TS around the lips & eyes
Appears in the form of papulopustular eruption
Discontinuation of TS & administration of systemic tetracycline is
effective

33. Periorificial dermatitis

34. Side effects of TS
• Glaucoma & cataract : if potent TS is applied around eyes
• Steroid acne:
o Comedones & pustules may be induced on face by TS
o Application of fluorinated TS to perianal skin results in comedones

35. Steroid acne

36. Side effects of TS
• Pustular psoriasis:
o Rebound phenomenon following withdrawal of TS may lead to pustular
stage of psoriasis as a complication of treatment of chronic plaque psoriasis

37. Pustular psoraisis

38. Side effects of TS
5. Systemic side effects
• They are unlikely except after:
 Prolonged wide spread application of TS in child
 Use of TS under occlusion on a large area of skin
 Use of very potent TS e.g. clobetasol propionate at dosage > 50 gm/week or
>100gm/week of potent TS

39. Side effects of TS
6. Contact sensitivity
 Extremely rare in relation to their use
 The reaction occurs to single or to closely related steroid configuration
 In many cases the responsible allergen is the vehicle of TS or preservative such as paraben
or ethylene diamine
 How can we reach such a diagnosis ?
The patient is presented with either chronic eczema non responsive to TS or with eruptions
suggestive of contact dermatitis. Patch test confirmation is needed
 Ears, anogenital areas & lower legs are more prone to develop this complication

40. Side effects of TS
• 7. localized hypertrichosis
• 8. skin infections
• 9. delayed wound healing

41. Localised hypertrichosis

42. Indications

43. Indications of TS
1. Eczema
 Atopic dermatitis
 Contact eczema
 Discoid eczema
 Xerotic eczema
 Pompholyx
2. Psoriasis
3. Lichen planus
4. Lichen striatus

44. Indications of TS
4. DLE
5. PLE
6. Intertrigo
7. Alopecia areata
8. Pemphigoid

45. Polymorphous Light Eruption

46. Bullous Pemphigoid

47. Fingertip unit
The amount of cream squeezed out of its tube onto the end of finger

49. Contraindications of TS
• Skin manifestations resulting from vaccination
• Cut. TB & Syphilis
• Bacterial, viral & fungal infections
• Perioral dermatitis
• Hypersensitivity to any constituent

51. Guidelines for use of TS
• Use of very potent TS should be restricted to:
• Short term application (Dermovate can be used in less than 50gm/week for only
2 weeks in adult without side effects)
• Applied on small surface area ( not more than 10% of total body surface)
• Chronic plaque psoriasis
• NOT to be used with occlusive dressing

52. Guidelines for use of TS
• Potent TS may be used for:
• Intermediate duration (3-4 weeks)
• short period (1-2 weeks) on the face & in intertriginous areas
• Application on surface area Not more than 20% of total body surface
• for severe eczema, lichen planus, lichen simplex chronicus, psoriasis & DLE.
• Potent TS should be used in children Only if mild or moderately potent
preparations do not yield the desired results. If essential , they should be used
only for the first 1 - 2 weeks initial treatment & lower potency preparations
should then be prescribed for maintenance treatment

53. Guidelines for use of TS
• Moderately potent TS should always be tried in eczema
• Mildly potent TS are:
• Safe for chronic application ( > 4weeks)
• Safest for use on the face & in intertriginous areas
• Safest for use in young children & infants

54. Guidelines for use of TS
• For treating patient with chronic eczema the step down ( in
potency ) therapy is used to achieve optimum benefit with
minimal adverse effects e.g. start with potent TS for 2-3
weeks then maintain with moderate potent TS for 3-4 weeks,
then gradual withdrawal

55. Guidelines for use of TS
• Frequency of application:
• Most active preparations are usually applied just once or twice daily
• With flourinated TS because of their depot effect, it may be possible to reduce
this to alternate days or less
• TS should be applied sparingly

56. Guidelines for use of TS
• Dilute or less potent TS can be used when larger areas of the body need to
be covered . Dilution of TS is done by cetomacrogol base. However,
manufactuer own diluent should be used because disturbance of the
physicochemical composition of the vehicle will alter bioavailability of TS

57. • Tachyphylaxis
• Repeated application of potent TS may result in a diminished effect of that
preparation
• This may occur within one week of initial use, but the ability to fully respond
returns within a week of stopping TS application
• This provides a reasonable basis for change of type of TS from time to time in
the course of treatment
• Intermittent application may avoid tachyphylaxis
Guidelines for use of TS

58. Guidelines for use of TS
• Occlusion & TS
• The use of plastic occlusive dressing may enhance the potency of TS by increasing
hydration of st. corneum
• It can be used in treatment of chronic eczema (hyperkeratotic & lichenified type)
• However , wide spread occlusion should not be used to avoid systemic absorption
of TS & other side effects such as :
• Disagreable odour
• Folliculitis & infection
• Miliaria
• Interference with heat exchange
• Reversible atrophy of adjacent skin

59. TS under occlusion

60. Folliculitis

62. Combinations

63. Combination of TS- Antimicrobial agents
• Used in treatment of eczema with 2ry infection,
diaper dermatitis & intertrigo
• They should not be used except in small quantities
& for short period

64. The antimicrobial agents used in combination
with TS are :
Vioform
Triclosan
Clotrimazole
Miconazole
NystatinGramicidin
Neomycin
Gentamycin
Na Fusidate

65. Other combinations
• TS- Salicylic acid combination
Salicylic acid has a keratolytic effect & enhance penetration of TS especially
in hyperkeratotic conditions
• TS- Tar combination:
• Tar may disturb the pharmaceutical stability of the delicate Ts structure
& such combination are best avoided
• If used the application of each should be separated in time

66. Other combinations
• TS – calcipotriol (vitamin d analogue) :
e.g Daivobet® ointment contains the active ingredients calcipotriol (50
microgram/g) betamethasone dipropionate (500 microgram/g).

67. Choice of vehicle
It is preferable to use
• Ointment V. in chronic dry lichenified & hyperkeratotic lesion
• Cream V. in acute weeping dermatoses
• Cream, gel & alcoholic lotion in hairy regions