Material and methods Double-blinded, Investigator-driven, randomized 50 female with melasma, 20-50 years old, assigned in 2 groups: •ST-CYS-5% 15min application + moisturizer + sunscreen (daily, 16weeks) •mKF overnight application (4% hydroquinone, 0.05% retinoic acid and 0.1% betamethasone) + moisturizer + sunscreen (daily, 16 weeks) Evaluation of mMASI score; Investigator Global Assesment & Patient questionnaires Evaluation at baseline, 8 weeks and 16 week

1. WHEN WE USE STEROID?

2. • Corticosteroids are among the widely used classes of medicine used
in dermatological disease as both short-term and long-term
treatments, although they are accompanied with a multitude of side
effects. Prescriptions should be audited on a regular basis to improve
prescribing quality, decrease side effects and prescribing errors,
provide criticism to physicians, and implementation of standard
treatment guideline.

3. • Topical corticosteroids are common medications prescribed for skin problems encountered in the
primary care or dermatology clinic settings. As skin conditions comprise of around 20% of cases
seen in primary care, this article written to guide readers, especially non-dermatologists on the
appropriate potency of topical corticosteroids to be chosen for skin problems of patients and to
list the side effects both local and systemic.
• Many skin conditions are treated with topical corticosteroids. This includes eczema, psoriasis,
lichen sclerosus, lichen planus, nodular prurigo, discoid lupus erythematosus and vitiligo; to name
a few. There are variety of factors to consider when choosing a topical corticosteroid including the
correct potency based on severity of clinical presentation, age group of patients, parts of the
body affected, and the balance between benefits versus side effects.
• More importantly, is the need for accurate clinical diagnosis to ensure the correct use for the
indication of topical corticosteroid and the need to exclude primary or secondary skin infection
prior to prescription. Microscopic examination of skin scraping with potassium hydroxide can help
in identifying superficial fungal skin infection as the condition may be worsened by the use of
topical corticosteroid. As skin conditions comprise of one fifth of the cases seen in primary care,
this article will offer guidelines to readers on the proper choice of corticosteroid for
dermatological conditions commonly seen by clinicians.

4. CHOOSING THE RIGHT POTENCY
• Topical corticosteroids come in either ointment (for dry or scaly lesions)
and lotion or cream formulation for wet lesions; with the ointment
formulation having the highest potency. The potency of steroids is
increased if occlusive dressing is used, especially in a hydrated area of the
body, damaged skin or in flexures such as axilla or groin.
• Skin absorption of topical corticosteroid varies greatly with the variation in
skin thickness at different body regions. Very thick skin at palms and soles
necessitates the use of potent topical corticosteroid due to reduced
absorption. Conversely, increased absorption in very thin skin at eyelids,
face and genitalia leads to high risk of adverse effects when even mild to
moderately potent topical corticosteroid is used at these areas for
prolonged period.

6. Generally, the use of topical corticosteroids should not be continued beyond two weeks without further
recommendation by the physician to minimise the risk of side effects. Most guidelines will suggest only low
potency topical corticosteroids to be used in children due to increased risk of side effects due to higher
body surface area in paediatric patients. A useful guide in prescribing steroids is adhering to the step-ladder
method akin to prescription to anaesthesia. This include coming down the ladder to a less potent
corticosteroid once the skin inflammation and pruritus improves, or going up the ladder for ineffective
response with a weaker corticosteroid, albeit for a maximum of two weeks duration before reviewing.

7. • There is also a need to be cautious about the correct potency
corticosteroids that are prescribed, e.g., hydrocortisone acetate 1% is
safe for use over the face or in children but not hydrocortisone
butyrate 0.1%. Most corticosteroid preparation will recommend a
daily or twice-daily application dose, with no further improvements
noted with more frequent applications.
• To ensure that the appropriate amount of corticosteroid is applied,
the usage of fingertip unit method is recommended, which is defined
as the amount squeezed from fingertip to the first crease of the
finger.

8. • Table II shows the number of fingertip units needed to for different
regions of the body. For example, the palm of a hand will require 0.5
fingertip units or 0.25g of corticosteroids. This will help physicians in
dispensing the right amount of topical corticosteroids

9. • Di bidang dermatologi, kortikosteroid sistemik banyak dipakai untuk penyakit yang
penyembuhannya lama atau penyakit berat yang menyebabkan kematian. Penelitian
dengan sampel besar dari General Practice Research Database di Inggris tahun 2000
melaporkan bahwa 0,9% populasi tersebut menggunakan kortikosteroid oral dan
penyakit kulit sebagai indikasi pemberian menempati urutan kedua sesudah penyakit
saluran napas. Sebagai antiinflamasi, kortikosteroid dibutuhkan dalam dosis tinggi, yakni
3-10 kali dosis fisiologis. Beberapa kasus bahkan membutuhkan terapi jangka panjang
untuk memperbaiki keadaan klinis, misalnya pada reaksi kusta. Hal ini menyulitkan dalam
menghindari efek samping, yang mencakup hampir semua sistem organ karena
kortikosteroid memengaruhi sebagian besar organ tubuh. Kortikosteroid termasuk
penyebab tersering perawatan di rumah sakit (RS) terkait efek samping obat, dan upaya
optimalisasi penggunaan obat ini telah menjadi fokus utama pada berbagai panduan
praktik klinik selama bertahun-tahun. Laporan efek samping bervariasi, antara 7%5 dan
33% pada penggunaan jangka pendek (60 hari, bahkan pada dosis rendah (≤7,5 mg/hari).
Di Indonesia, dataunit rawat jalan (URJ) Kulit dan Kelamin Rumah Sakit Umum Daerah
(RSUD) Dr. Sutomo Surabaya tahun 2009-2011 menunjukkan bahwa efek samping
kortikosteroid oral pada reaksi kusta tipe 2 adalah 8,9%.

10. • Keputusan menggunakan kortikosteroid sangat membutuhkan
pertimbangan yang cermat akan manfaat dan risiko pada setiap
pasien. Makalah ini membahas aspek farmakologi dan penggunaan
klinis kortikosteroid sistemik pada kelainan kulit, agar dengan
mengoptimalkan pemilihan preparat, rejimen dosis, interval dan
waktu pemberian, lama terapi, metode tapering off, serta
pemahaman terhadap potensi interaksi obat, kemungkinan efek
samping dapat dibatasi dalam rangka meningkatkan keamanan
pasien.

11. • Pemberian dosis kortikosteroid bersifat sangat individual tergantung
kondisi penyakit, farmakokinetik preparat, potensi interaksi, serta respons
terapi. Pada kelainan endokrin, dosisnya mendekati dosis fisiologis,
sedangkan pada gangguan non-endokrin diberikan dosis terapi untuk
menekan inflamasi. Toksisitas kortikosteroid berhubungan dengan dosis
rata-rata dan akumulasi lama penggunaan, namun batas ambang dosis
atau lama terapi belum dapat ditetapkan. Saat stres, dosis ditingkatkan
untuk mencegah krisis adrenal. Stres ringan berupa aktivitas fisik, emosi,
imunisasi, dan penyakit virus tanpa komplikasi tidak membutuhkan rejimen
tambahan. Dosis tambahan diperlukan pada trauma, demam, muntah,
diare, penurunan asupan oral, luka bakar luas, letargi, serta pembedahan.,

16. Take home messages
• Topical corticosteroid can be either an ally or foe when prescribed for the
treatment of a skin condition. Protocols exists for the proper use of
corticosteroids taking into account potency of the steroids, age of the
patient, severity of the dermatoses and patient preference. Primary care
physician should empower themselves and their patients about the
indications of usage of topical corticosteroids and the anticipated benefits
and risks.
• More emphasis should be placed on rational and comprehensive
corticosteroids prescribing for skin diseases. The baseline data generated
by these studies can be used by researchers and policymakers to enhance
prescribing practices. Continuing medical education is also critical for
professional physicians to put it into action and ensure success. This will
help to improve corticosteroid prescribing by providing education during
consultations.