Corticosteroids and Topical Therapies



Corticosteroids and Topical Therapies


Susan Busch

Gail Batissa Lenahan



The skin is a large and complex organ that performs multiple functions allowing us to maintain a state of homogeneity. As a barrier, it protects against chemicals, microorganisms, ultraviolet radiation (UVR), and the loss of bodily fluids. It is a nutritive organ supplied by a network of superficial vessels that nourish and repair the skin. Constant vasodilation and constriction of blood vessels, along with the cooling response of sweat glands, accomplishes temperature regulation.

These functions can alter the moisture content in the skin and subsequently affect the penetration and efficacy of topical preparations. Percutaneous absorption (PCA) of topical treatments also varies depending on the thickness of the skin on different areas of the body. For instance, eyelid, antecubital, axillae, and genital skin are very thin and medication is quickly absorbed. The skin of the palms, soles, knees, and elbows is thicker, decreasing the rate of the absorption of medications applied. The presence or absence of occlusion also affects product permeability, rate, and potency of medications used.

This chapter will explore various topical formulations and the most appropriate use of each in the treatment of common dermatologic conditions. Sunscreens and their proper use will be presented, and an overview of botanical products will be outlined.

Systemic agents, specifically corticosteroids, are often used in dermatology, and we will review their optimum indications and usage. At times, oral agents may seem to be a more convenient option; however, topical therapies are often the better choice. With the correct usage of topical corticosteroid (TCS) therapies, side effects will be minimized.


SKIN HEALTH

Patients often ask about proper skin care. They are besieged with advertisements about the best and latest “miracle cream” and often believe that cost is equated with efficacy. For some, it is merely a factor of cosmesis, but many seek help because of uncomfortable and sometimes disfiguring skin conditions. Providing accurate information regarding product ingredients will help patients make better, more informed choices when faced with the myriad of options.


Cleansing

Everyone can benefit from a good skin care regimen. Recommendations regarding bathing and hand washing vary depending on a person’s age, activity, environment, culture, and skin condition. Cleansing the skin too often can contribute to worsening of certain skin conditions such as acne and eczema. The use of antibacterial soaps, abrasive materials, and gadgets are not necessary, and can be harmful to the skin by contributing to antibiotic resistance, irritation, or allergic reactions.


Environment

Protecting the skin from all types of weather is important. Sun, wind, cold, and humidity can hinder the skin’s protective function. In dryer climates, moisturizers should be applied within minutes of bathing to help prevent water evaporation and skin cracking, which can predispose patients with certain skin conditions to infection. Oil-free and noncomedogenic products are recommended for the skin of the face, while thicker moisturizers and those containing urea or lactic acid are more effective in treating hyperkeratotic skin commonly seen on the feet. Lactic acid, an α-hydroxy acid, is useful for softening dry, thick skin. This ingredient can also cause skin irritation and should not be used on delicate or inflamed skin.

In very cold climates, dry air from heating systems enhances water evaporation and contributes to the overall dryness of the skin. In humid climates, light-weight breathable clothing can help skin to remain dry. In all climates, sunscreen should be applied to exposed areas in the morning and reapplied every 2 hours when staying in the sun.

Healthy lifestyles also help maintain a person’s youthful skin appearance. Incorporating regular exercise, maintaining a proper diet, minimizing alcohol intake, and avoiding smoking and excessive stress are key factors in protecting the skin from aging prematurely.


Irritants and Allergens

Individuals with sensitive skin should choose products less likely to include common allergens such as fragrances, dyes, lanolin, propylene glycol, and parabens. If there is a suspected allergy, referral to a dermatologist can help the patient identify the allergens through patch testing (see chapter 3). Furthermore, dermatologists can provide patients with lists of personal hygiene products (a “safe” list) that they should avoid and those that are free of specific allergens. Patients are still warned to check the ingredient list of all products; even those on the safe list can change ingredients without any notice. Otherwise, primary care clinicians can provide some general guidance on widely available moisturizers that are free of the most common allergens (Table 2-1). Patients should be warned that the label “hypoallergenic” does not mean that the product does not contain common sensitizers. This is a marketing claim used by manufacturers and is not standardized or monitored. It only means that the product may cause fewer allergic reactions or has lower amounts of common sensitizers compared to other brands.

Yet not all dermatitis is caused by allergens. Frequent hand washing with soap and water is sometimes necessary, but can aggravate skin that is already affected by dermatitis. Hand dermatitis may be due to allergens in cleansers or irritation from the harsh chemical ingredients that can damage the epidermis and trigger inflammation. Water itself is the most common irritant in hand dermatitis and
is often seen in health care workers. The use of a mild cleanser or a gel sanitizer made with at least 60% alcohol provides a less drying alternative. Alcohol gel sanitizers can prevent cracking and drying of the skin and should be used only on intact skin when hands are not visibly soiled.








TABLE 2-1 Brand-Name Products Free of the Most Common Allergens*




















CATEGORY

PRODUCT†


Wipes

7th Generation Free & Clear Baby Wipes


Cleansers

Aveeno Baby Cleanser Moisturizing Wash


Eucerin Skin Calming Dry Skin Body Wash


Free & Clear Liquid Cleanser for Sensitive Skin


Vanicream Gentle Facial Cleanser


VML Hypoallergenics Essence Skin-Saving Clear & Natural Soap


Spring Cleaning Purifying Facial Wash for Oily Skin


Moisturizers

Aveeno Eczema Therapy Moisturizing Cream Baby


Eczema Therapy Moisturizing Cream


Cetaphil Oil Control Moisturizer SPF


Eucerin Professional Repair for Extremely Dry Skin


Lotion


Vaniply Ointment for Sensitive Skin


VML Hypoallergenics Red Better Daily Therapy


Moisturizer


Lubricants

Fragrance- and preservative-free: Aquaphor


Fragrance-, lanolin-, and preservative-free: white petrolatum or petroleum jelly


*Formaldehyde, fragrance (including botanicals), paraben mix/parabens, and propylene glycol.

† Retailers may sell old formulations of the brand. Manufacturers may change the formulation at any time and without warning or notice to consumers.



TOPICAL THERAPIES


Moisturizers

Throughout this text, we will discuss skin conditions which involve, among other factors, a loss of the skin’s barrier function. When the skin is dry, the epidermis cannot perform its protective function, allowing microbes and allergens easy access to stimulate inflammation and/or infection. To maintain hydration and proper barrier function, the skin should be cleansed daily with lukewarm water and dried with a patting motion (not rubbed vigorously) to preserve the oils in the skin. Within 3 minutes of a shower or bath, a moisturizer or emollient should be applied to the entire body. This helps to “seal” in the water and increase moisture in the stratum corneum.

Moisturizer is a term commonly used when referring to any topical that is applied to treat dry skin. Products that are actually moisturizers hydrate the skin by drawing water into the stratum corneum through the use of humectants such as urea, glycerin, lactic acid, or glycolic acid. Emollients soften the skin and can offer a protective barrier with a layer of oil or another occlusive agent. Products may have one or both properties, and selection of the topical is an individual preference based on texture, odor, and location of the application. Moisturizers are available as ointments, creams, and lotions. Ointments offer the most hydration and greatest barrier and are especially effective for thick, dry, and scaly areas.

Moisturizers are also used for cosmetic purposes and can be applied several times a day, particularly after hand washing. Many contain sunscreen, fragrances, alcohol, preservatives, and other chemicals mentioned above that are known to cause contact dermatitis. Patients with allergies should be instructed to apply the best agent for their dry skin but to avoid known agents that can trigger contact dermatitis.


Wet Dressings

When skin integrity has been altered and the skin becomes weepy or wet, several wet dressing options are available over the counter. Aluminum acetate powder (Domebero) is a medication that can be mixed with water for its antiseptic and drying properties. Acetic acid solution can be prepared by adding a half cup of household white vinegar to a pint of water for its bactericidal quality. Patients should be instructed to soak clean facecloths in the liquid and wring them out before placing on the weeping rash. These hypertonic treatments are effective in drying blisters and are commonly used for severe sunburns, poison ivy rashes, or moist intertrigo, but must only be used until the wet aspect of the condition has resolved.

Application is recommended two to four times per day for no longer than 30 to 60 minutes. Cool temperature water is used to decrease inflammation, while lukewarm water may be used to stimulate circulation in an infectious process.

In the pediatric population, especially those children with atopic dermatitis, plain wet dressings are recommended to help with the itch. In these cases, an emollient or TCS ointment (if prescribed) is applied first, followed by plain-water-soaked gauze, and covered with dry dressings or cotton pajamas and left on overnight. Wet dressings should never be occluded with plastic wrap as this increases the risk for maceration and increases bacterial growth.


Bleach Baths

Bleach baths can also be used for patients who are at higher risk for superficial skin infections. Patients with atopic dermatitis or recurrent skin and soft tissue infections from methicillin-resistant staphylococcus aureus (MRSA) can benefit from sitting in a warm bleach bath once to twice weekly for 10 minutes to reduce the bacteria count on their skin, and reduce the itching experienced by these patients. The bath is made from one quarter of a cup of unscented household bleach in a full bathtub. This dilutes the bleach to avoid any harmful effects. The skin is then treated with an emollient immediately after exiting the bath.


Cosmetic Botanicals

Clinicians are often asked about skin care products, specifically those containing natural ingredients (Table 2-2). There is some evidence to suggest that botanical products may be useful, but the scientific data are lacking. For patients with sensitive skin, eczema, atopic dermatitis, inflammatory or pruritic conditions, products containing feverfew, colloidal oatmeal, or sunflower seed oil may provide some soothing relief. Patients with rosacea and pigmented lesions may benefit from products containing licorice root extract, which has skin lightening and anti-inflammatory properties.

Botanical extracts are being used with increased frequency in the cosmetic industry, and the future of antiaging products, in particular, appears to be promising. Today many cosmetic formulations are made of botanical extracts and may improve the health, texture, and integrity of the skin, hair, and nails. Botanicals are also being used in cleansers, moisturizers, and astringents. Therefore, it is important to have an understanding of the expected benefit of these products.

Table 2-2 includes a synopsis of the more popular botanical ingredients used in skin care products today, but does not represent
all botanicals on the market and is not an endorsement. Patients with skin disorders should always use caution before using any new topical products, as they may include ingredients that can cause contact dermatitis. Providers can guide patients away from allergens included in these products that can initiate an irritant or an allergic response, no matter how “natural” the ingredients.








TABLE 2-2 Common Botanicals











































































































NAME

ORIGIN

EFFECT

USE


Aloe

Leaves of Aloe vera

Emollient, preventing infection

Eczema, wound care, ringworm, burns, insect bites


Arnica

Flowers of Arnica montana

Anti-inflammatory

Wound care, bruising, eczema, blisters (Avoid use on broken skin), acne, chapped lips


Calendula

Flowers of Calendula officinalis (pot marigold)

Antifungal, anti-inflammatory

Radiation induced burns, decubitus ulcers, bruising


Cayenne

Fruit of Capsicum annuum

Analgesic, warming stimulant

Neuropathic pain from shingles, massage oils, psoriasis


Chamomile

Dried flower heads and oil from Matricaria chamomilla

Antioxidant, antimicrobial, analgesic, anti-inflammatory

Wound care, burns


Chocolate

Seeds of Theobroma cacao

Antioxidant

Cocoa butter for chapped skin, burns, irritants


Dandelion

Leaves, flowers, or root of Taraxacum officinale

Anti-inflammatory, antioxidant, antibacterial, possible antitumor activity

Eczema, psoriasis, acne


Eucalyptus

Leaves, oil from Eucalyptus globulus

Antiseptic, astringent

Skin abscesses, minor wounds, bruises


Feverfew

Leaves, flowering tops of Tanacetum parthenium

Antioxidant, anti-inflammatory, anti-irritant, and anticancer properties. Orally, chewing leaves can cause ulceration and oral edema

Rosacea, antiaging, atopic dermatitis


Green Tea

Leaves, buds from Camellia sinensis

Anti-inflammatory, antioxidant

Healing wounds and photoprotection


Lavender

Flowers, essential oil from Lavandula angustifolia

Fragrance, antimicrobial, antianxiety

Fragrance, sleep inducer, sunburn, fungal infection, as rub form circulatory and rheumatic ailments


Lemongrass

Leaves, young stems, and oil of Cymbopogon citratus

Antiseptic, antibacterial, antifungal

Athlete’s foot, ringworm


Licorice root extract*

Underground stem of Glycyrrhiza glabra

antioxidant, anti-inflammatory, antiviral and antimicrobial

Skin lightening, healing for herpes blisters, canker sores, sunburn, insect bites


Patchouli

Leaf, stem of Pogostemon cablin

Antibacterial, antifungal

Eczema, seborrhea, acne, eczema, mosquito repellent


Resveratrol

Skin and seeds of grapes, berries, peanuts, and other foods

antioxidant, anti-inflammatory, and antiproliferative agent

Antiaging, wrinkle reduction


Rosemary

Leaves, twigs from Rosmarinus officinalis

Anti-inflammatory, antioxidant, analgesic

Seborrhea, alopecia


Soy

Seeds from Glycine max

Antioxidant, anticarcinogenic, anti-inflammatory

Skin lightening, improve skin elasticity, moisturizer


Tea tree oil

Leaves from Melaleuca alternifolia

Antifungal, antimicrobial, anti-inflamamtory

Acne, onychomycosis, ringworm, dandruff eczema, insect bites


Witch hazel

Leaves, bark, twigs of Hamamelis virginiana

Astringent, antioxidant, anti-inflamamtory

Acne, contact dermatitis, bites, burns


* The oral form of licorice root extract can interact with angiotensin-converting enzyme inhibitors, aspirin, oral contraceptives, oral corticosteroids, diuretics, insulin, and stimulant laxatives.


Adapted from Foster, S., & Johnson, R. L. (2006). Desk reference to nature’s medicine. Washington, DC: National Geographic Society.




CORTICOSTEROIDS

Corticosteroids play a significant role in the treatment of dermatologic disorders. The fact that they can be used topically, intralesionally, and systemically provides the clinician numerous options for patient management. Corticosteroids are a synthetic derivative of the natural steroid, cortisol, which is produced by the adrenal cortex. There are two types of corticosteroids, glucocorticoids and mineralocorticoids. Glucocorticoids are the drugs most often used in dermatology and will be the focus of discussion in this chapter. In general, regardless of the method of administration, these drugs act as anti-inflammatory, immunosuppressive, and antiproliferative agents. When they are used topically, their vasoconstrictive properties determine their potency, and they are used to treat a wide range of disorders from acute allergic dermatitis to chronic immunobullous disorders. We will look more closely at these frequently used medications in the next two sections and will discuss their mode of administration, indications, and side effects and will make recommendations for use depending on the severity of the disorder.


Topical Corticosteroids

Many conditions seen in primary care and dermatology can be appropriately treated with a TCS. They penetrate the skin and work by decreasing the inflammatory pathways that cause the skin to become red and inflamed. Within days of use, however, the production of new skin cells is suppressed, creating the risk of atrophy and striae with long-term usage. The following factors can have an effect on treatment success and should be considered when prescribing any topical medication.


Percutaneous absorption

The ability of a topical medication to be effective is dependent on the transdermal delivery of the active ingredients from the stratum corneum of the epidermis to the underlying capillaries. There are many variables which can promote or impede PCA, including drug concentration, frequency of administration, occlusion, surface area involved, the vehicle, age and weight of patient, location on the body, and amount of time the topical is left on the skin. PCA is increased with hydrated (moist) skin, heat or elevated temperature, and the condition of skin barrier.


Vehicles

Topical agents are prepared in a variety of vehicles or bases that constitute the inactive portion of the medication, allowing the drug to be delivered into or through the skin (Table 2-3). Generic formulations of TCS may vary in the contents of the vehicle. Contact allergies may worsen if a generic product is substituted for a brand-name prescription. Vehicles can also alter the potency of the corticosteroid itself, which is why a drug may be class 1 in an ointment form but a different class in a cream or lotion vehicle. Additionally, consistency of the vehicle can be important.


Strength/frequency

A concentration of 1% indicates 1 g of drug will be contained in 100 g of the formulation. Efficacy of a topically applied drug is usually not proportionate to the concentration. Doubling or halving the concentration often has a surprisingly modest effect on the response. Occlusion increases the penetration and ultimately the effectiveness of the product. Compounding of proprietary products with other ingredients may alter the stability of the drugs and should be done with caution if at all.








TABLE 2-3 Vehicles for Topical Preparations



















VEHICLE

DEFINITION

PREFERENCES


Solution

Homogenous mixture of two or more substances

Excellent for scalp/hair-bearing areas


Lotion

Liquid preparation, thicker than solution


Likely to contain oil, water, and/or alcohol

Lotions spread easily.


Use in large areas


Cream

Thicker than lotion


Requires preservatives to extend shelf life Greater potential for allergic reactions

Use when skin is moist or exudative.


Can be used in any area

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May 25, 2016 | Posted by in Dermatology | Comments Off on Corticosteroids and Topical Therapies

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