This document provides information about topical corticosteroids (TCS) including their structure, absorption rates in different areas of the skin, mechanisms of action, classification systems, factors affecting choice of TCS, indications, side effects, topical steroid withdrawal, myths versus realities about TCS use, and take home messages. It discusses how TCS were successfully used to treat eczematous dermatoses in 1952 and reviews their anti-inflammatory, immunosuppressive and vasoconstrictive effects. The document also addresses classification, side effects like striae, cross reaction groups, topical steroid withdrawal syndrome, its clinical presentation and treatment, and myths versus realities about TCS use and TSW.

1. Welcome
PRESENTED BY
DR A M MUSADDIK HOSSAIN KHAN
PHASE B RESIDENT
DEPARTMENT OF DERMATOLOGY AND
VENEREOLOGY
BSMMU

2. In dermatology

3. ;

4. Introduction
 Sulzberger and witten treated
eczematous dermatosis with topical
hydrocortisone in 1952
 This success made a new cornerstone in
the history of dermatology

5. CS have a basic structure of cyclopentanoperhydrophenanthrene
ring(17c)formed by fusion of 3 six membered ring and 1 five membered
ring

15. Absorbtion at different sites
Forearm 1%
Armpits 4%
Face 7%
Eyelids and genitals 30%
Palm .1%
Sole .05%

17. Effects of TCS
Figure 2: Anti-inflammatory, immunosuppressive, and vasoconstrictive effects of topical
corticosteroids

18. Effects cont

20. Effects cont

21. Effects cont

22. Effects cont

23. Effects cont

24. Effects cont

26. Cont

29. Classification

30. Classification cont

32. Clssification cont

33. Factors affecting choice of TCS
 Anatomic area of application
 Disease responsiveness
 Severity of the disease
 Extent of BSA involvement
 Age of the patient
 Suitability of the vehicle
 Potency of steroid molecule

35. Indication cont

37. Side effects

38. Side effects cont

40. Striae

48. TCS cross reaction groups

65. Topical steroid withdrawl(TCW)
 TSW is a skin condition that may be associated with the use of topical
steroids which are medications used to treat various skin condition such as
eczema and psoriasis
 Exact cause and mechanism are not clear because not everyone who uses
TCS will develop TSW
 Also known as red skin syndrome or topical steroid addiction
 TSW is a relatively rare and under recognized condition

66. Clinical presentation
 There is a range of clinical presentations and symptoms
 In general there is red,itchy,dry and burning skin that affect small area to
nearly the whole body
 Recurrent scratching for severe itching may breaks the skin barrier that
may lead to skin infection
 There may be oozing,bleeding and cracking

67. TSW cont
 Extreme tiredness
 Insomnia
 Rapid weight loss
 Hair loss
 Excessive flaking of skin
 Lymph node swelling
 Swelling of legs and arms
 Feeling cold
 Anxious

68. TSW treatment
 There is no agreed treatment of TSW
 Cessation of TCS
 A tapering course of oral steroid may be helpful
 Oral tetracycline and low dose isotretenoin have been used in steroid
rosacea perioral dermatitis
 Cold compression
 Psychological support
 Oral antibiotis in case of infection

69. prevention
 Avoid prolonged and frequent use of high potency TCS
 Risk of TSW should not prevent appropriate management of atopic
dermatitis

70. Myths vs reality of TSW
TCS should not be used for treatment of eczema due to
of local and systemic side effect
TCS have been proven to be safe treatment even in children
when used carefully and continue to be important therapies
for calming inflamed skin
TSW is a worse version of normal TCS side effects TSW is a unique adverse event that is separate from other TCS
side effects.it typically affects face,neck and genital areas upon
stopping TCS therapy
Once affected with TSW the condition is irreversible TSW can be treated by discontinuing the TCS and providing
supportive care
Regular use of TCS will result in TSW A recent study reviewed that TSW results from frequent,
inappropriate and prolonged use of moderate to high potency TCS
primarily on the face and genital area.appropriate use of TCS as
prescribed is unlikely to predispose patients to TSW
Physicians can accurately predict the frequency/duration of TCS
usage needed to prevent TSW
Although TCS can be safely prescribed to avoid predisposing patients
to TSW there is still much that remains unknown about the
condition.The exact rate of how common TSW is and minimum
frequency and duration of TCS usage can lead to it are still a
mystery,making close follow up and frequent re evaluation important
for all receivingTCS

71. Myth vs Reality
Physicians can accurately predict
individual Predisposed to develop TSW
Greatest predisposing factor is chronic
misuse of TCS especially those of mid to
higher potency beyond the regimen
was originally prescribed
Physical symptoms of TSW are very easy
to diagnose and are uniform among all
patients
Physicians have yet to pinpoint the set of
symptoms that are definitely associated
with TSW and there is variability in how
different patients present.some TSW
symptoms also overlap with other
condition such as allergic contact
dermatitisfurther complicating the
diagnosis.however patients who
experience any of the most common
symptoms of burning/stinging,worsening
with heat or sun,itching,facial hot flushes
within 3 weeks of stopping TCS usage
should consult

72. Take home message

73. Take care
 No steroid should be used without a
doctor’s prescription
 How much is to be used has to be
told by your dermatologist
 Never reuse your older prescription
for a recurrent or new rash
 Do not self treat
 Do not apply creams to skin that is
infected or has open wounds
 Do not share prescription with
relatives and friends for their
treatment
 Wash your hand before and after use
 Take care of your skin by judicious use

74. Thank you