Eczema - Patient's guide

Topical Corticosteroid Dosing, Mechanisms of Action, & Prescribing

Dosing of creams and ointments

A useful measuring technique that is most often used by dermatologists for topical application is the Finger-tip Unit (FTU), which is the amount of ointment expressed from a tube with a 5mm diameter nozzle, applied from the distal skin-crease to the tip of the index finger. [Cllin Exp Dermatol. 1991 Nov; 16(6):444-7.]

Estimating the Necessary Amount of Topical Corticosteroid for Adults

Anatomic area	FTU required to cover an area	Amount for twice daily application (gm)
Face and neck	2.5	2.5
Anterior/ posterior trunk	7	7
Arm	3	3
Hand (both sides)	1	1
Leg	6	6
Foot	2	2

FTU = Finger-tip Unit [adapted from Long CC, Finaly AY: Clin Exp Dermatol 1991 Nov;16(6):444-7]

Estimating the Necessary Amount of Topical Corticosteroid for Children

Anatomic area		FTU required to cover an area				Amount for twice daily application (gm)
		3-6 mos.	1-2 yrs.	3-5 yrs.	6-10 yrs.	3-6 mos.	1-2 yrs.	3-5 yrs.	6-10 yrs.
Face and neck		1	1.5	1.5	2	1	1.5	1.5	2
Arm and hand		1	1.5	2	2.5	1	1.5	2	2.5
Leg and foot		1.5	2	3	4.5	1.5	2	3	4.5
Anterior trunkPosterior trunk and buttocks		1	2	3	3.5	1	2	3	3.5
Posterior trunk and buttocks		1.5	3	3.5	5	1.5	3	3.5	5

FTU = Finger-tip Unit

[adapted from Long cc, Mills CM, Finaly AY: Br J Dermatol 1998;138:293-6]

Corticosteroid Mechanisms of Action

Epidermis

• Number of keratinocyte mitoses is diminished
• Stratum corneum thickness reduced
• Granular layer reduced or absent
• Melanocyte pigment production inhibited

• Dermal volume reduced – decreased water content, loss of glycosaminoglycans
• Collagen and elastic fibers unchanged
• Late Atrophy (Continuation of the Atrophogenic Process)
• Dermal volume reuced
• Collagen and elastic fibers diminished and abnormally aggregated
• Hypoactive fibroblasts (as above)
• Dermal vessels fragile, due to loss of fibrous and ground substance support

Some general rules for prescribing topical corticosteroids

1. Very responsive diseases require mild or moderately potent formulations, less responsive diseases require potent or very potent formulations.
2. Mild formulations should only be used on the face, groin, axillae, genital and perianal areas.
3. Very potent formulations should be used for short periods of time (14-20 days) or intermittently to reduce adverse events.
4. Potent or very potent formulations are usually required on palms, soles and for lichenified and hypertrophic dermatoses.
5. Brief use of a more potent steroid achieves faster control of eczema and may result in less steroid use, compared with long use of inadequately potent preparations.
6. Occlusion is often needed on palms and soles to enhance penetration of the active molecule through the thicker stratum corneum.
7. Corticosteroids should not be used on ulcerated or atrophic skin.
8. Sudden discontinuation should be avoided after prolonged use to prevent rebound phenomenon.
9. When treating children, special guidelines should be followed to avoid the disadvantages of under-application or the occurrence of systemic or local adverse effects due to overdosage.
10. Laboratory tests for adrenal suppression are performed by some after long periods of therapy and/or treatment of large areas.

Precautions to consider

Carcinogenicity
Long-term animal studies to determine the carcinogenicity of topical corticosteroids have not been done.

Pregnancy
Topical corticosteroid preparations may cause fetal abnormalities in animals if used in large amounts with occlusive dressing for prolonged periods of time, or if more potent agents are used. Fetal abnormalities due to topical corticosteroids have not been documented in humans. It is not known whether topical corticosteroid molecules are excreted in breast milk, but no adverse effects during lactation have been reported. Topical corticosteroids are classified in FDA Pregnancy Category C.

[Warner M, Camisa C. Topical Corticosteroids. In: Comprehensive Dermatologic Drug Therapy, Wolverton SE, Editor. Philadelphia: W.B. Saunders Company, 2001; pp 548-77.]

Potential Local Side Effects

• Epidermal atrophy – the most common local side effect characterized by lax, wrinkled, thin skin with telangiectasias, purpura, striae, stellate psuedoscars, hypopigmentation or prominent deep vessels. It may be seen within the first 7 days of daily superpotent corticosteroid application under occlusion and within 2 weeks of daily application of a less potent corticosteroid. Significant atrophy is generally seen after many weeks or months of application, but striae have been observed on a man’s medial thighs after 2 weeks of proprietary combination of betamethasone dipropionate 0.05% and clotrimazole 1% cream. Most signs of cutaneous atrophy resolve by 1-4 weeks after discontinuation, however, striae are permanent.
• Steroid addiction/rebound – characterized by initial improvement with a topical corticosteroid, followed by lack of response after continue application, followed by a flare after corticosteroid withdrawal. The treated skin might appear erythematosus and the patient might report a burning sensation.
• Glaucoma/cataracts – penetration around the eyelid skin can be 36-40 times that of thicker skin such as the palm or sole. Prolonged use on cunjunctival tissue can lead to glaucoma, cataracts, reduced healing or traumatic ulcers, exacerbation of herpetic ulcers, and greater susceptibility to fungal and bacterial infections. Glaucoma and blindness have occurred after 12 years of intermittent use of 1% hydrocortisone cream for periorbital involvement of atopic dermatitis. Glaucoma also occurred in a patient with a history of hand eczema, for which he had been using 0.1% betamethasone-17-valerate cream at bedtime for the previous 7 years in varying frequency.
• Allergic or irritant contact dermatitis in response to a corticosteroid is suspected with a corticosteroid-sensitive dermatitis fails to respond readily to, or worsens with corticosteroid therapy.

• Hydrocortisone
• Hydrocortisone acetate
• Cortisone acetate
• Tixocortol pivalate
• Prednisolone
• Methylprednisolone
• Prednisone

• Triamcinolone acetonide
• Triamcinolone alcohol
• Amcinonide
• Bedesonide
• Desonide
• Fluocinonide
• Fluocinolone acetonide
• Halcinonide

• Betamethasone
• Betamethasone sodium phosphate
• Dexamethasone
• Dexamethasone sodium phosphate
• Fluocortolone

• Hydrocortisone-17-butyrate
• Hydrocortisone-17-valerate
• Aclometasone dipropionate
• Betamethsone valerate
• Betamethasone dipropionate
• Prednicarbate
• Clobetasone-17-butyrate
• Clobetasol-17-propionate
• Fluocortolone caproate
• Fluocortolone pivalate
• Fluprednidene acetate

Cutivate® (Fluticasone propionate)

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• INTRODUCTION
  A synthetic fluorinated corticosteroid recently introduced to Canada but has been available in the U.S market for a number of years. Fluticasone propionate is classified as a medium potency topical corticosteroid...   |   Read more ...



• CLININCAL EXPERIENCE
  Topical corticosteroids are extensively used. Atopic eczema will be used as a model for discussing this new topical corticosteroid. A concern with the use of any long term medication is the potential for...   |   Read more ...



• INDICATIONS
  Used for all inflammatory and pruritic conditions that are corticosteroid responsive e.g. eczema, psoriasis and dermatitis. It should not be used in rosacea, acne, or perioral dermatitis... Read more ...



• PATIENT PROFILE
  4 double blind randomized controlled studies in 772 adults and children showed the once the acute episode of moderate to severe eczema had been treated effectively that twice weekly...   |   Read more ...



• DOSING
  For the acute stage of eczema daily application of Cutivate is recommended. New evidence guides us to apply Cutivate twice a week to maintain control of eczema...   |   Read more ...



• EFFICACY
  Although not indicated for use on children in Canada, studies have shown that once daily application is safe and effective in children with atopic eczema...   |   Read more ...



• COMPLIANCE
  Daily application in the acute phase and thereafter twice weekly maintaince should help with compliance ...   |   Read more ...



• SIDE EFFECTS, SAFETY AND RISKS
  Approx 270 million packs sold since 1990 in US ...   |   Read more ...



• COST OF TREATMENT
  Cost of this drug is in line with other potent topical corticosteroids. Cost effectiveness is seen if effective clinical response is realized. The utilization of a twice a week regimen significantly reduces costs...   |   Read more ...

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