A lecture by Dr. Naya Talal Hassan (Master Degree in Dermatology and STIs) about topical corticosteroids (TCS), that are used very commonly in dermatology. It contains important information which every dermatologist should know.

1. Topical Corticosteroids
By:
Dr.Naya Talal Hassan
Dermatology Department, Tishreen University
Latakia, Syria

3. •Corticosteroids (adrenal cortical steroids) arenaturalhormones
made by the adrenal cortex.
•Cholesterol is the sole precursor of steroids.
•Theycan beproducedthrough industry.
•Industrial steroids arestronger than the naturallyoccurring
hormone.
What are
Corticosteroids?

4. History
Steroidalhormoneswereisolated
fromtheadrenalcortex.
1930s
Steroidalhormoneswere
synthesised
1940s
SulzbergerandWittenfirsttreated
atopicdermatitswithtopical
steroid.
1952
Hench,Kendall& Reichstein
1950

5. The efficiency ofcorticosteroids to treat wide
range of inflammatory conditionsincluding
rheumatoidarthritis and asthma marked the birth
of a
wonder drug

6. A topicalcorticosteroidis appliedto aparticularplacethe body(mainly thebodysurfacessuchas theskin ormucous
membranes).
A topicalsteroidis ananti-inflammatorypreparationusedtocontroleczema andmanyotherskinconditions.
Topicalsteroidsareavailablein creams,ointments,solutionsandothervehicles.
Topicalsteroidsarealso calledtopicalcorticosteroids,glucocorticosteroids,andcortisone.
What is a topicalcorticosteroid?

7. How does atopical steroid work?
The effects of topical steroid on various cells in the skin are:
Anti-inflammatory
Immunosuppressive
Anti-proliferative
Vasoconstrictive.

9. through Lipocortin

10. The potency of topical steroid
The potency of a topical steroid depends on:
The specificmolecule
The amount thatreaches the target cell
Absorption through the skin
Formulation
“Potency is also increased when a formulation is used under occlusive dressing or in intertriginous
areas”

12. 01 Very potent or
superpotent
Clobetasolpropionate
Betamethasonedipropionate(in anoptimisedvehicle)
(up to600 times as potent as hydrocortisone)
Hydrocortisone
Hydrocortisoneacetate
04 Mild
Clobetasonebutyrate
Triamcinoloneacetonide
(2–25 times as potent as hydrocortisone)
03 Moderate
Betamethasonevalerate
Betamethasonedipropionate(cream, ointment,gel)
Diflucortolonevalerate
Hydrocortisone17-butyrate
Mometasonefuroate
Methylprednisoloneaceponate
(100–150 times as potent as hydrocortisone)
02 Potent

14. As a general rule:
We use theweakestpossible steroid thatwill do the job. It isoften appropriate to use a potent
preparation for a short time to ensure theskin condition clears completely.

15. A topical steroid is absorbed in different rates depending on skinthickness.
The greatest absorption occurs through the thin skinof eyelids, genitals, and skincreases
when a potent topical steroid should be avoided.
The leastabsorption occurs through the thick skin of palms and soles, where a mild topical
steroid is ineffective.
Absorption also depends on the vehicle in which the topical steroid is delivered and is greatly
enhanced by occlusion.

16. Formulations of topical steroid
Several formulationsare availablefortopicalsteroids,intendedtosuitthetypeofskinlesionandits
location.
Creams andlotions:are themostpopularformulations.
Ointment:
• The most suitable formulation for dry, non-hairy skin
• No requirement for preservative, reducing risk of irritancy and contact allergy
• Occlusive, increasing risk of folliculitis and miliaria
Gelorsolution:
• Useful in hair-bearing skin
• Has an astringent (drying) effect
• Stings inflamed skin

17. Combination products
• Topical steroid is sometimes combined with
another active ingredient, including
antibacterial, antifungalagent or calcipotriol.
• Topical corticosteroid/antibiotic preparations should be used rarely, and short-term (eg, three
times daily for one week for a small area of infected dermatitis), to reduce the risk
of antimicrobial resistance.

20. Later phase of
allergic/irritant contact
dermatitis.
( )

21. What are the sideeffects oftopical
steroid?
• Side effects are uncommon or rare when topical steroids are used appropriately under medical
supervision.
• Topicalsteroid may be falselyblamed for a sign when underlying disease or another condition is
responsible (for example, postinflammatory hypopigmentation or undertreated atopic eczema).

22. Cushing syndrome
Internal side effects similar to those due to systemic steroid (Cushing syndrome) are rarely
reportedfrom topical steroids, and only after long-term use of large quantities of topical steroid
(eg > 50 g of clobetasol propionate or > 500 g of hydrocortisone per week).
Cases of Cushing syndrome due to topical corticosteroids most often occur because of
inappropriate prescribing or over the counter salesof corticosteroids in countries where that is
permitted.

23. Cutaneous side effects
Skin thinning(atrophy)
Stretch marks(striae) in armpits or groin
Easy bruising (senile/solar purpura)and tearing of the skin
Enlarged blood vessels (telangiectasia)
Localised increased hair thickness and length (hypertrichosis)
Hypo/hyperpigmentation
A ggravate or mask skin infections such as impetigo, tinea, herpes simplex
,malassezia folliculitis and molluscum contagiosum.
Periorificial dermatitis (commonwith potent steroids); this can occurin children
Steroid rosacea
Symptoms dueto topical corticosteroid withdrawal (Psoriasis).
Stinging frequentlyoccurs when a topical steroid is first applied, due to underlying inflammation and brokenskin.
Contact allergy to steroid molecule, preservative or vehicle is uncommonbut may occurafter the first application of the product or after manyyears of its
use.

24. Local side effects may arise when a potent topical steroid is applied dailyfor long periods oftime (months). Mostreports of side effects describe prolonged use of
an unnecessarily potent topical steroid forinappropriateindications.

25. Ocularside effects:
Atopical steroid should beused cautiously on eyelid skin,
where it commonlyresults in periocular dermatitis.
Potentially, excessive use overweeks to months might lead
to glaucoma or cataracts.
Topical steroid in pregnancy:
Mild and moderate-potency topical steroids can be
safely used in pregnancy. Caution should be used
for potent and ultrapotent topical steroids used over
largeareas or under occlusion, of which a proportion
will beabsorbed systemically.
Reports of low birth-weight infants exposed to high-dose
topical steroid are not thought to be due to the medication.

26. Topical corticosteroid (TCS) phobia
It refers to the negative feelings and beliefs related to TCSsexperienced by patients and patients' caregivers. This phenomenonmaybe a major
contributing factor in treatment failure in patients with atopic dermatitis, yetit has been sparsely described in the literature.

27. How to use a topical steroid?
• Topical steroid is applied usuallyonce daily (usuallyat night) to inflamed skinfor a course of 5
days to several weeks. After that, it isusuallystopped, or the strength or frequency of application
is reduced.
• Emollients can be applied before or after the application of topical steroid, to relieve irritation
and dryness or as a barrier preparation. Infection may need additional treatment.

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