>> Clinical Guidelines

Topical Corticosteroids

Topical Corticosteroids are effective, cosmetically acceptable and safe if used carefully under supervision.

Efficacy

A wide selection of products is available ranging from very mild (e.g. 1 per cent hydrocortisone) to highly potent (e.g. 0.05 per cent clobetesol propionate) enabling accurate titration of the potency of the preparation prescribed against the patient's needs. The potency of the cream or ointment used depends not only on the inherent activity of the steroid molecule itself and its concentration, but also on the excipient in the vehicle used in the formulation. Topical corticosteroids are best used on limited areas of psoriasis. More resistant areas such as the hands, feet and scalp can initially be treated by potent corticosteroids from the onset. There is no evidence that twice daily application of topical steroids is more effective than once daily application. The strength of the steroid should be adjusted commensurate with clinical improvement. In especially resistant psoriasis of the limbs, hands or feet, occlusive treatment in which the treatment area is covered by a thin polythene film will greatly enhance effectiveness (and also local and systemic toxicity). This measure should only be continued for a few days at a time. Flexural areas are usually self occluded and therefore require only mild potency topical steroid treatment, as does the face and neck.

Safety, side-effects and tolerance

Corticosteroid resistance (tolerance) may develop and the use of corticosteroids may be accompanied by local side effects especially if occlusive therapy has been used. These include thinning of the skin and telangiectasia (usually reversible) and irreversible steroid striae. Other side effects include rapid relapse time and transformation to unstable or pustular psoriasis. In extreme cases systemic toxicity including pituitary adrenal suppression and the clinical features of Cushing's syndrome may be caused by extensive percutaneous absorption. These risks are related not only to the potency of the preparation used but also to the total daily amount applied. If appropriate guidelines are followed (below) the use of a British National Formulary mild steroid on the face and flexural areas, and a moderate or, in exceptional circumstances and for a short period a high potency corticosteroid elsewhere is acceptable.

Rarely glaucoma may occur from the use of topical steroids on the eyelids and periorbital area. Systemic toxicity is also more likely to occur in infants and small children because of the large surface area relative to mass. Tolerance may occur in response to continued use of any topical steroid and is related to duration of use rather than potency. Its mechanism is unknown. Use of alternative non-steroid topical treatment usually results in recovery of responsiveness to the corticosteroid. Contact allergy is occasionally a complication of topical corticosteroid treatment and can be confirmed by appropriate patch testing. Newer steroids including mometasone, prednicarbate and fluticasone propionate are more rapidly inactivated or metabolised following percutaneous absorption although retaining local efficacy and local potential for adverse effects. No unsupervised repeat prescriptions should be made: patients should be reviewed every 3 months

·         No more than 100 g of a moderately potent or higher potency preparation should be applied per month

·         Attempts should be made to rotate topical corticosteroids with alternative non-corticosteroid preparations

·         Use of very potent or potent preparations should be under dermatological supervision. The fingertip unit is a measure which helps patients to know how much ointment or cream to apply.

·         No topical corticosteroid should be used regularly for more than four weeks without critical review.

·         Potent corticosteroids should not be used regularly for more than 7 days.

Synergy with other treatments

A topical corticosteroid can be used as a monotherapy or in conjunction with other topical agents including tar or dithranol. Some patients who fail to respond to one topical agent may respond to another and it is worthwhile rotating different classes of topical agents before abandoning topical treatment altogether.  

This information forms part of the current BAD guidance document for the general management of psoriasis.  Other sections in the document comprise: