Topical corticosteroids have revolutionised the treatment of inflammatory skin diseases, since they were introduced in 1952. They are very effective treatment options for many skin diseases and have revolutionised the management of eczema, allergies and other inflammatory skin diseases like psoriasis. Their effectiveness is prompt and most acute allergies can be cured within a few days. For chronic illnesses, like Atopic Eczema in children and psoriasis, they have to be used for a longer duration.

But, If not used with proper titre of dose and strength, they can cause damage to the skin, sometimes permanent. There are many unscientific formulations masquerading as anti-fungal creams and whitening or bleaching creams in the market, where one of the ingredient is potent or super potent steroid. Thus topical steroid creams are double edged swords, the use of which should be carefully titred according to their potency, stage of disease, age of the patient and site of application.

A knowledge of different classes of topical steroids according to their potency is important for everyone prescribing or using these effective and useful medications.

From the above it is clear that  topical corticosteroids  should be carefully chosen according to their potency, stage of disease, age of the patient and site of application. This is of paramount importance and all those who use these wonderful medications, including patients, pharmacists and doctors should be aware of their strengths and indications of use.

Topical corticosteroids come in several forms, including creams, lotions and ointments. Creams and solutions are a class below in potency than ointments. Ointments are greasy and preferred in chronic dermatitis and scaly diseases like psoriasis. Creams can be used in acute and subacute skin inflammation. Gels and lotions are preferred in hairy areas and scalp.

Side Effects of Topical Corticosteroids

Topical steroids have both topical (limited to skin) and systemic side effects.

Topical Side Effects of Topical Steroids Limited to Skin

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• Topical application of steroids causes thinning of the skin by causing atrophy of the skin layers.
• Dilation of capillaries that are shown through the thinned skin, known as telengiectasia.
• Stretching and splitting of the skin causing stretch marks or striae dystensiae.
• Pimple like eruptions on the treated area, especially on the face, chest, back and limbs, called steroid acne.
• The main problem with topical (and systemic steroids) is the rebound phenomenon or exacerbation of the lesions that occur if the steroids are suddenly stopped or withdrawn. A localized form of psoriasis can become generalized or a generalized form can get precipitated as pustular or erythrodermic forms when steroids are withdrawn.
• Higher strength steroids should be avoided on the face, especially near eyes, on the body folds and near the genital organs. Steroids used near eyes for prolonged duration have been shown to cause cataract formation in the eyes and glaucoma.
• Steroids are best avoided in the presence of infection as these can exacerbate infections.
• Other topical side effects of topical steroids include easy bruising, purpura, skin ulceration, non healing of ulcers, exacerbation of infections, perioral dermatitis, rosacea, hypo pigmentation, hyper pigmentation, and excessive hair growth. Mistaken application of steroids on ring worms cause changes in morphology and spread of the fungal infection, known as tinea incognito.

Systemic Side Effects of Topical Steroids

• Adrenal Suppression. Because of the absorption of potent steroids into the blood stream, the adrenal glands could become suppressed and their production of normal steroids will suffer as a result. This can have far reaching effects on the body. If prolonged, this can produce a cushingoid (moon like) face in patients and cause other systemic effects.
• Tachyphylaxis.The body develops resistance to the topical application after some time.

How to Avoid Topical Steroid Side Effects

1. Topical Steroids are wonder drugs for many skin diseases like eczema and skin allergies but should be used only under supervision of a skin specialist or a modern medicine doctor who is trained to use it.
2. Never buy steroid containing creams directly from pharmacy
3. Avoid using fairness, whitening or bleaching creams from saloons, parlours and unlabelled sources. These may contain very strong steroids and cause serious damage to your skin.
4. Avoid using so called anti-fungal creams containing steroids. When in doubt, consult a skin specialist before using such creams.
5. Potent and super-potent steroid creams should only be used under the supervision of a skin specialist.
6. Never use steroid containing creams in the presence of infection or if diagnosis is not sure.
7. Use appropriate graded strength according to severity, age, site of involvement.
8. Gradual withdrawal and replacement with safer creams should be resorted to.
9. Superpotentà Potent à Moderate à Least Potent.  Shift down as the condition improves.
10. Application free interval: 5-7 days after every two weeks of application helps avoid side effects.
11. Never use higher strength topical steroids in infants and children.
12. Avoid moderate to superpotent classes of topical steroids in sensitive areas like face and body folds.
13. Once acute phase is under control, shift to steroid sparing calcineurin inhibitors like Tacrolimus, Pimecrolimus.

Disclaimer

The information given in this article is for educational purpose only so that patients are aware of the options available for diagnosis and treatment of common skin, hair and nail diseases. No diagnosis should be made or treatment undertaken without first consulting your dermatologist. If you do so, the author will not be responsible for any consequences. The images provided are for illustration purpose only and should not be reproduced without the consent of the author.

About the Author of Skin Care Tips from Dermatologist: Dr Hanish Babu, MD

Dr Hanish Babu, MD is a dermatologist with more than 3 decades of experience in treating skin and sexually transmitted diseases in UAE and India. He has been practicing in UAE since last 22 years. He is a respected speaker during the Continuing Medical education Programmes for doctors, medical students and paramedical staff and is also a Stress Management Trainer. He organises group therapy sessions for patients with psoriasis, eczema and vitiligo.

He is available for consultation at Cosmolaser Medical Centre in Samnan, Sharjah (06 5678 200) from 10 am – 2 pm and at City Medical Centre, Al Bustan, Ajman (06-7 441 882) from 4.30 pm – 9.30 pm.

Visit his personal website  dr-hanishbabu.com for more details and for educational articles on Skin, hair, nail and sexually transmitted diseases. Click here to Book an Appointment with dermatologist Dr Hanish Babu, MD