Indications

Eczema - the most important because it is very common both in adults and children (affecting 15-20% of school children and 2-10% of adults). Children are most at risk from misuse and adverse effects. See Atopic Eczema article. Contact dermatitis Seborrhoeic dermatitis (antifungals probably more appropriate1) Insect stings Eczema associated with infection - with caution Psoriasis - with caution Other inflammatory skin conditions including: discoid lupus erythematosus; lichen planus under specialist supervision. Choice of formulation is important: o o o o Creams are best for weeping or moist areas. Ointments are best for dry scaly or lichenified areas. Lotions are useful for larger or hair bearing areas. Occlusive dressings increase absorption. Caution and close supervision is required.

Potency of steroid should be matched to age, disease severity and site . For example: o Face, genitals and flexures: o Eyelids: o Skin is thin. Restrict to intermittent mild steroid for no more than 14 days and avoid eye contact. Over age 35 beware risk of glaucoma if used for more than 14 days and monitor IOPs. Skin is thin and self occludes within the skin fold, thus increasing absorption. Milder steroids should therefore be prescribed.

Palms, soles of feet and scalp: Skin is thicker. Stronger steroids required. Consider occlusive techniques.

Trunk and limbs in adults: Use weakest strength required to achieve control within 14 days as judged by severity of the inflammation and prior response to treatment.

Children:

Use weaker steroids especially when large area to be treated. Consider specialist referral if moderate strength steroids are needed to maintain control.

Duration of treatment: o o o Treatment gives only symptomatic relief and duration of treatment should be limited to a week for acute conditions. In more chronic conditions use for 4-6 weeks to achieve remission (for example in chronic eczema). Short bursts of stronger steroids can be used to gain control over a few days. 12

Quantity of steroid: o Give specific information on the quantity to be applied (as too much risks side effects and too little may be ineffective). This can be specified according to the calculation that one FTU (finger tip unit, or length squeezed from tube between tip of finger and first skin crease) is enough to cover an area about twice the area of the palmar aspect of the hand (and weighs approximately 500 mg). No more than twice daily should be applied and the NICE guidelines 13 suggest that once daily may be as effective as more frequent applications. This may also reduce side effects. Specific guidance on how much cream or ointment should be prescribed is helpful. For example, a guide to quantities from the BNF for an acute eczema flare up in adults is:

Face and neck

30g

Both hands

30g

Scalp

30g

Both arms

60g

Both legs

100g

Trunk

100g

Groin and genitalia

30g

Use of emollients14: o o o Topical steroids should not be used for emollient effect. Emollients should be applied at least 30 minutes before the topical steroid. Frequent and intensive emollient use in eczema will reduce the amount of steroid needed.

Monitoring of treatment: o o o Regular review of treatment should be undertaken to ensure that minimum strength required is being used and to check for side effects. Care should be taken to follow up more closely use of stronger steroids, children, and in areas of the body where skin is thin. Immunomodulatory agents such as tacrolimus and pimecrolimus are now available as an alternative to topical steroids. These are as effective but more expensive. Initiation usually requires referral.

Topical corticosteroids are contraindicated in: Untreated infection (bacterial, fungal and viral) Acne rosacea Perioral dermatitis Extensive plaque psoriasis

They should be used with caution in children, certain sites (see below) and psoriasis.

Cara kerja kortikosteroid topical : Menurunkan inflamasi dengan menekan migrasi PMN (leukosit) dan meningkatkan permeabilitas kapiler. Klasifikasi Kortikosteroid Topikal berdasarkan potensinya 1. Sangat kuat a. betametason dipropionat b. halsinonid

c. desoximetason 2. Kuat a. hidrocortison valerat b. betametason valerat : 0.1%(Valison) solution/lotio

Dewasa : gunakan pada daerah lesi bid

Apply to affected areas qd/bid; solutions and lotions tend to be thin and good for scalp application
Pediatric

Administer as in adults Kontra Indikasi : hypersensitivity, infeksi viral / fungal

c. triamcinolon asetonid d. fluocinolon asetonid 3. Sedang a. hidrocortison butirat b. flumetason 4. Lemah a. Hidrocortison b. Dexametason c. metil prednisone
Class 1 Very potent (up to 600 times as potent as hydrocortisone)

Class 2

Clobetasol propionate (Dermol Cream/Ointment Betamethasone dipropionate (Diprosone OV Cream/Ointment)

Potent (I00-150 times as potent as hydrocortisone)

Betamethasone valerate (Beta Cream/Ointment/Scalp Application, Betnovate Lotion/C Cream/C Ointment, Daivobet 50/500 Ointment, Fucicort) Betamethasone dipropionate (Diprosone Cream/Ointment) Diflucortolone valerate (Nerisone C/Cream/Fatty Ointment/Ointment)

Hydrocortisone 17-butyrate (Locoid C/Cream/Crelo Topical Emulsion/Lipocream/Ointment/Scalp Lotion)

Class 3

Mometasone furoate (Elocon Cream/Lotion/Ointment) Methylprednisolone aceponate (Advantan Cream/Ointment)

Moderate (2-25 times as potent as hydrocortisone)

Clobetasone butyrate (Eumovate Cream) Triamcinolone acetonide (Aristocort Cream/Ointment, Viaderm KC Cream/Ointment, Kenacomb Ointment)

Class 4 Mild

Hydrocortisone 0.5-2.5% (DermAid Cream/Soft Cream, DP Lotion-HC 1%, Skincalm, Lemnis Fatty Cream HC, Pimafucort Cream/Ointment)

Topical steroids are also available in combination with salicylic acid to enhance penetration, and with antibacterial and antifungal agents.

Skin absorption of topical steroids

Steroids are absorbed at different rates from different parts of the body. A steroid that works on the face may not work on the palm. But a potent steroid may cause side effects on the face. For example:

Forearm absorbs 1% Armpit absorbs 4% Face absorbs 7% Eyelids and genitals absorb 30% Palm absorbs 0.1% Sole absorbs 0.05%

Efek samping obat sistemik : Osteoporosis, gangguan sintesis kolagen (gangguang penyembuhan luka), miopati (hasil dari katabolisme protein) Edema, hipertensi, CHF retensi Na dan air

Gangguan SSP : euphoria-psikose Ulkus peptikum Cushing syndrome : obese sentral, moon face, pertumbuhan rambut bertambah, acne, insomnia, napsu makan bertambah Withdrawel : sangat berbahaya, karena supresi hipotalamus-pituitary-adrenal menyebabkan adrenal insufisiensi sindrom Psikosis, glikosuria, hiperkoagulabilitas darah dengan terjadinya tromnboemboli Infeksi sekunderimunosupresan

Efek samping obat lokal : Memperburuk kondisi pada mata merah akibat HSVhilang penglihatan Glaucoma steroid Katarak steroid

Side effects of topical steroids

Internal side effects If more than 50g of clobetasol propionate, or 500g of hydrocortisone is used per week, sufficient steroid may be absorbed through the skin to result in adrenal gland suppression and/or eventually Cushing's syndrome.

Adrenal Gland Suppression. Topical steroids can suppress the production of natural steroids, which are essential for healthy living. Stopping the steroids suddenly may then result in illness. Cushing's Syndrome If large amounts of steroid are absorbed through the skin, fluid retention, raised blood pressure, diabetes etc. may result.

Skin side effects Local side effects of topical steroids include:

Skin thinning (atrophy) and stretch marks (striae). Easy bruising and tearing of the skin. Perioral dermatitis (rash around the mouth). Enlarged blood vessels (telangiectasia). Susceptibility to skin infections.

Disguising infection e.g. tinea incognito. Allergy to the steroid cream.

The risk of these side effects depends on the strength of the steroid, the length of application, the site treated, and the nature of the skin problem. If you use a potent steroid cream on your face as a moisturiser, you will develop the side effects within a few weeks. If you use 1% hydrocortisone cream on your hands for 25 years, you will have done no harm at all (except for having wasted a lot of money!)

Systemic side effects: o These are more likely with more potent steroids, larger quantities, more frequent application and where absorption is greatest (certain sites of the body and occlusion enhance absorption). o Children by virtue of skin type, surface area to weight ratio and disease severity are more at risk of systemic side effects and should be monitored closely. The risk of growth retardation exists and growth should be monitored under specialist supervision where moderate strength steroids are required regularly. Safe weekly limits to avoid systemic side effects have been suggested: 18

Treatment period in months

Mild to moderate

Poten t

Very potent

Less than 2 months

100g

50g

30g

2-6 months

50g

30g

15g

6-12 months

25g

15g

7.5g

Localised adverse effects: o Effects such as skin thinning are unlikely to occur in less than 4 weeks in mild to moderate strength steroids but can occur with potent steroid within 1-3 weeks. This will often, but not always, reverse within 4 weeks if stopped. If potent steroids are required for control of inflammation for more than 7 days in a 5 week period referral is recommended because of the risk of local side effects. 11

Local side effects include:

Spreading infection

Depigmentation Skin thinning Striae Telangiectasia Contact dermatitis Perioral dermatitis Acne Acne rosacea

Avoidance of infection may be promoted by steroid-antibiotic combinations (evidence lacking), emollient antimicrobial preparations, not leaving tubs open, pump dispensers, general hand hygiene measures.

http://www.patient.co.uk/doctor/Steroids-and-the-Skin.htm http://dermnetnz.org/treatments/topical-steroids.html