Topical corticosteroids

13.4 Topical corticosteroids

Topical corticosteroids are used for the treatment of inflammatory conditions of the skin (other than those arising from an infection), in particular eczema (section 13.5.1), contact dermatitis, insect stings (p. 36), and eczema of scabies (section 13.10.4). Corticosteroids suppress the inflammatory reaction during use; they are not curative and on discontinuation a rebound exacerbation of the condition may occur. They are generally used to relieve symptoms and suppress signs of the disorder when other measures such as emollients are ineffective.

Topical corticosteroids are of no value in the treatment of urticaria and they are contra-indicated in rosacea; they may worsen ulcerated or secondarily infected lesions. They should not be used indiscriminately in pruritus (where they will only benefit if inflammation is causing the itch) and are not recommended for acne vulgaris.

Systemic or potent topical corticosteroids should be avoided or given only under specialist supervision in psoriasis because, although they may suppress the psor- iasis in the short term, relapse or vigorous rebound occurs on withdrawal (sometimes precipitating severe pustular psoriasis). Topical use of potent corticosteroids on widespread psoriasis can lead to systemic as well as to local side-effects. It is reasonable, however, to pre- scribe a mild to moderate topical corticosteroid for a short period (2–4 weeks) for flexural and facial psoriasis and to use a more potent corticosteroid such as beta- methasone or fluocinonide for psoriasis of the scalp, palms , or soles (see below for cautions in psoriasis).

In general, the most potent topical corticosteroids should be reserved for recalcitrant dermatoses such as chronic discoid lupus erythematosus , lichen simplex chron- icus , hypertrophic lichen planus, and palmoplantar pustu- losis . Potent corticosteroids should generally be avoided on the face and skin flexures, but specialists occasion- ally prescribe them for use in these areas in certain circumstances.

When topical treatment has failed, intralesional cortico- steroid injections (section 10.1.2.2) may be used. These are more effective than the very potent topical cortico- steroid preparations and should be reserved for severe cases where there are localised lesions such as keloid scars , hypertrophic lichen planus, or localised alopecia areata .

Perioral lesions Hydrocortisone cream 1% can be used for up to 7 days to treat uninfected inflammatory lesions on the lips and on the skin surrounding the mouth. Hydrocortisone and miconazole cream or ointment is useful where infection by susceptible organ- isms and inflammation co-exist, particularly for initial treatment (up to 7 days) e.g. in angular cheilitis (see also p. 610). Organisms susceptible to miconazole include Candida spp. and many Gram-positive bacteria includ- ing streptococci and staphylococci.

Children Children, especially infants, are particularly susceptible to side-effects. However, concern about the safety of topical corticosteroids in children should not result in the child being undertreated. The aim is to

control the condition as well as possible; inadequate treatment will perpetuate the condition. A mild cortico- steroid such as hydrocortisone 1% ointment or cream is useful for treating nappy rash (section 13.2.2) and for atopic eczema in childhood (section 13.5.1). A moder- ately potent or potent corticosteroid may be appro- priate for severe atopic eczema on the limbs, for 1–2 weeks only, switching to a less potent preparation as the condition improves. In an acute flare-up of atopic eczema, it may be appropriate to use more potent formulations of topical corticosteroids for a short per- iod to regain control of the condition. A very potent corticosteroid should be initiated under the supervision of a specialist. Continuous daily application of a mild corticosteroid such as hydrocortisone 1% is equivalent to a potent corticosteroid such as betamethasone 0.1% applied intermittently. Carers of young children should

be advised that treatment should not necessarily be reserved to ‘treat only the worst areas’ and they may need to be advised that patient information leaflets may contain inappropriate advice for the patient’s condition.

Choice of formulation Water-miscible corticosteroid creams are suitable for moist or weeping lesions whereas ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required. Lotions may be useful when minimal applica- tion to a large or hair-bearing area is required or for the treatment of exudative lesions. Occlusive polythene or hydrocolloid dressings increase absorption, but also increase the risk of side-effects; they are therefore used only under supervision on a short-term basis for areas of very thick skin (such as the palms and soles). The inclusion of urea or salicylic acid also increases the penetration of the corticosteroid.

In the BNF topical corticosteroids for the skin are categorised as ‘mild’, ‘moderately potent’, ‘potent’ or ‘very potent’ (see p. 623); the least potent preparation which is effective should be chosen but dilution should

be avoided whenever possible.

Cautions Avoid prolonged use of a topical cortico- steroid on the face (and keep away from eyes). In children avoid prolonged use and use potent or very potent corticosteroids under specialist supervision; extreme caution is required in dermatoses of infancy including nappy rash—treatment should be limited to 5–

7 days. Psoriasis The use of potent or very potent corticosteroids in psoriasis can result in rebound relapse, development of gen-

eralised pustular psoriasis, and local and systemic toxicity.

Contra-indications Topical corticosteroids are con- tra-indicated in untreated bacterial, fungal, or viral skin lesions, in rosacea, and in perioral dermatitis; potent corticosteroids are contra-indicated in widespread plaque psoriasis (see notes above).

Side-effects Mild and moderately potent topical corti- costeroids are associated with few side-effects but care is required in the use of potent and very potent corticos- teroids. Absorption through the skin can rarely cause adrenal suppression and even Cushing’s syndrome (sec- tion 6.3.2), depending on the area of the body being treated and the duration of treatment. Absorption is greatest where the skin is thin or raw, and from inter-

13.4 Topical corticosteroids BNF 57

Skin

BNF 57

13.4 Topical corticosteroids 623

triginous areas; it is increased by occlusion. Local side- ciated with bacterial or fungal infection, such as infected effects include:

eczema. In these cases the antimicrobial drug should be .

spread and worsening of untreated infection; chosen according to the sensitivity of the infecting .

thinning of the skin which may be restored over a organism and used regularly for a short period (typically period after stopping treatment but the original

twice daily for 1 week). Longer use increases the like- structure may never return;

lihood of resistance and of sensitisation. .

irreversible striae atrophicae and telangiectasia; .

contact dermatitis; .

perioral dermatitis;

Topical corticosteroid preparation

. acne, or worsening of acne or rosacea;

potencies

. mild depigmentation which may be reversible; Potency of a topical corticosteroid preparation is a result of the .

hypertrichosis also reported. formulation as well as the corticosteroid. Therefore, proprie- tary names are shown below.

In order to minimise the side-effects of a topical

Mild

0.1–2.5%, Dioderm , Mildison , affected areas only, no more frequently than twice

corticosteroid, it is important to apply it thinly to

Hydrocortisone

Synalar 1 in 10 dilution daily, and to use the least potent formulation which

Mild with antimicrobials: Canesten HC, Daktacort, is fully effective.

Econacort , Fucidin H, Nystaform-HC, Timodine, Vio- form-Hydrocortisone

Application

Mild with crotamiton: Eurax-Hydrocortisone should be applied no more frequently than twice daily;

Topical corticosteroid preparations

once daily is often sufficient.

Moderate

Eumovate , Haelan , Modrasone , length of cream or ointment expelled from a tube may

Topical corticosteroids are spread thinly on the skin; the

Betnovate-RD ,

Synalar 1 in 4 Dilution , Ultralanum Plain

Moderate with antimicrobials: Trimovate area of skin. This length can be measured in terms of a

be used to specify the quantity to be applied to a given

Moderate with urea: Alphaderm, Calmurid HC fingertip unit (the distance from the tip of the adult index

finger to the first crease). One fingertip unit (approxi- mately 500 mg) is sufficient to cover an area that is

Potent

twice that of the flat adult palm. Betamethasone valerate 0.1%, Betacap, Bettamousse, Betnovate , Cutivate, Diprosone, Elocon, Hydrocorti-

Suitable quantities of corticosteroid pre- sone butyrate, Locoid, Locoid Crelo, Metosyn, Nerisone parations to be prescribed for specific areas , Synalar

of the body

Potent with antimicrobials: Aureocort, Betnovate-C, Betnovate-N , Fucibet, Lotriderm, Synalar C, Synalar N

Potent with salicylic acid: Diprosalic Face and neck

Creams and Ointments

15 to 30 g Both hands

15 to 30 g

Very potent

Scalp 15 to 30 g Clarelux , Dermovate, Etrivex, Nerisone Forte Both arms

30 to 60 g Both legs

100 g Trunk

100 g Groins and genitalia

HYDROCORTISONE

Indications mild inflammatory skin disorders such as These amounts are usually suitable for an adult for a

15 to 30 g

eczemas (but for over-the-counter preparations, see single daily application for 2 weeks

Skin

below); nappy rash, see notes above and section If a patient is using topical corticosteroids of different

potencies, the patient should be told when to use each Cautions see notes above corticosteroid. The potency of each topical cortico-

Contra-indications see notes above steroid (see Topical Corticosteroid Preparation Poten-

Side-effects see notes above cies, below) should be included on the label with the

Dose

directions for use. The label should be attached to the . Apply thinly 1–2 times daily container (for example, the tube) rather than the outer

packaging. Hydrocortisone (Non-proprietary) A Mixing topical preparations on the skin should be

Cream , hydrocortisone 0.5%, net price, 15 g = £3.04, avoided where possible; several minutes should elapse

30 g = £5.19; 1%, 15 g = £2.70, 30 g = £3.65, 50 g = between application of different preparations. The prac-

£16.96; 2.5%, 15 g = £24.03. Label: 28, counselling, tice of using an emollient immediately before a topical

application, see above. Potency: mild corticosteroid is inappropriate.

Dental prescribing on NHS Hydrocortisone Cream 1% 15 g may

be prescribed

Ointment , hydrocortisone 0.5%, net price 15 g = Compound preparations The advantages of includ-

£3.57, 30 g = £5.23; 1%, 15 g = £2.55, 30 g = £3.55, ing other substances (such as antibacterials or anti-

50 g = £25.22; 2.5%, 15 g = £32.53. Label: 28, coun- fungals) with corticosteroids in topical preparations

selling, application, see above. Potency: mild are uncertain, but such combinations may have a

place where inflammatory skin conditions are asso- When hydrocortisone cream or ointment is prescribed and no strength is stated, the 1% strength should be supplied

13.4 Topical corticosteroids BNF 57 Over-the-counter hydrocortisone preparations

Daktacort c (Janssen-Cilag) A Skin creams and ointments containing hydrocortisone

Cream , hydrocortisone 1%, miconazole nitrate 2%, (alone or with other ingredients) can be sold to the

net price 30 g = £2.08. Label: 28, counselling, appli- public for the treatment of allergic contact dermatitis,

cation, see p. 623. Potency: mild irritant dermatitis, insect bite reactions and mild to

Excipients include butylated hydroxyanisole, disodium edetate

moderate eczema, to be applied sparingly over the

A 15-g tube is on sale to the public for the treatment of affected area 1–2 times daily for max. 1 week. Over-

Note

athlete’s foot and candidal intertrigo the-counter hydrocortisone preparations should not

Ointment , hydrocortisone 1%, miconazole nitrate 2%,

be sold without medical advice for children under 10 net price 30 g = £2.09. Label: 28, counselling, appli- years or for pregnant women; they should not be sold

cation, see p. 623. Potency: mild for application to the face, anogenital region, broken

Excipients none as listed in section 13.1.3

Dental prescribing on NHS or infected skin (including cold sores, acne, and ath- May be prescribed as Miconazole and Hydrocortisone Cream or Ointment for max. 7 days lete’s foot). Econacort c (Squibb) A Cream , hydrocortisone 1%, econazole nitrate 1%, net Proprietary hydrocortisone preparations c price 30 g = £2.25. Label: 28, counselling, application, Dioderm (Dermal) A see p. 623. Potency: mild

Cream , hydrocortisone 0.1%, net price 30 g = £2.50.

Excipients include butylated hydroxyanisole

Label: 28, counselling, application, see p. 623. Fucidin H Potency: mild c (LEO) A Excipients include cetostearyl alcohol, propylene glycol

Cream , hydrocortisone acetate 1%, fusidic acid 2%, Note Although this contains only 0.1% hydrocortisone, the for-

net price 30 g = £5.30, 60 g = £10.60. Label: 28, mulation is designed to provide a clinical activity comparable to that of Hydrocortisone Cream 1% BP

counselling, application, see p. 623. Potency: mild Excipients include butylated hydroxyanisole, cetyl alcohol, polysorbate

60, potassium sorbate

Mildison c (Astellas) A Ointment , hydrocortisone acetate 1%, sodium fusi- Lipocream , hydrocortisone 1%, net price 30 g = £2.45.

date 2%, net price 30 g = £3.26, 60 g = £6.53. Label: 28, counselling, application, see p. 623.

Label: 28, counselling, application, see p. 623. Potency: mild Excipients include cetostearyl alcohol, hydroxybenzoates (parabens)

Potency: mild Excipients include cetyl alcohol, wool fat

Compound preparations Nystaform-HC c (Typharm) A Cream Compound preparations with coal tar see section , hydrocortisone 0.5%, nystatin 100 000 units/

g, chlorhexidine hydrochloride 1%, net price 30 g =

13.5.2 £2.66. Label: 28, counselling, application, see p. 623. Alphaderm Potency: mild c

(Alliance) A Excipients include benzyl alcohol, cetostearyl alcohol, polysorbate ‘60’ Cream , hydrocortisone 1%, urea 10%, net price 30 g = £1.98; 100 g = £5.86. Label: 28, counselling, applica-

Ointment , hydrocortisone 1%, nystatin 100 000 units/ tion, see p. 623. Potency: moderate

g, chlorhexidine acetate 1%, net price 30 g = £2.66.

Excipients none as listed in section 13.1.3

Label: 28, counselling, application, see p. 623. Potency: mild

Calmurid HC c (Galderma) Excipients A none as listed in section 13.1.3 Cream , hydrocortisone 1%, urea 10%, lactic acid 5%,

net price 30 g = £2.80, 50 g = £4.67. Label: 28, coun- A

Timodine c (R&C)

Cream , hydrocortisone 0.5%, nystatin 100 000 units/ selling, application, see p. 623. Potency: moderate

g, benzalkonium chloride solution 0.2%, dimeticone

Skin

Excipients none as listed in section 13.1.3 Note Manufacturer advises dilute to half-strength with aqueous

‘350’ 10%, net price 30 g = £2.38. Label: 28, counsel- cream for 1 week if stinging occurs then transfer to undiluted

ling, application, see p. 623. Potency: mild

13 preparation (but see section 13.1.1 for advice to avoid dilution

Excipients include butylated hydroxyanisole, cetostearyl alcohol, where possible)

hydroxybenzoates (parabens), sodium metabisulphite, sorbic acid

1 c Vioform-Hydrocortisone (Novartis Consumer Health) Eurax-Hydrocortisone c (Novartis Consumer Health)

A Cream , hydrocortisone 1%, clioquinol 3%, net price Cream , hydrocortisone 0.25%, crotamiton 10%, net

30 g = £1.46. Label: 28, counselling, application, see price 30 g = 87p. Label: 28, counselling, application,

p. 623. Potency: mild see p. 623. Potency: mild

Excipients include cetostearyl alcohol Excipients include fragrance, hydroxybenzoates (parabens), propylene glycol, stearyl alcohol

Ointment , hydrocortisone 1%, clioquinol 3%, net

1. A 15-g tube is on sale to the public for treatment of contact price 30 g = £1.46. Label: 28, counselling, application, dermatitis and insect bites

see p. 623. Potency: mild Excipients none as listed in section 13.1.3 Note Stains clothing

With antimicrobials See notes above for comment on compound preparations