Misuse and abuse of topical steroids: implications

Abstract

Topical steroids, having revolutionized dermatotherapy over several decades, remain the mainstay of treatment for steroid-responsive inflammatory dermatoses worldwide. Challenges, nevertheless, abound on the usage of topical steroids, particularly with their inappropriate application. Several steps and improved formulations are constantly evolving in the scientific world, aimed at addressing most of the associated adverse events. However, until the dawn of the 'ideal topical steroid', the implications of application misuse will remain significant. This review discusses the concept of 'misuse and abuse' of topical steroids, gives an overview of topical steroids, differentiates 'misuse' as opposed to 'abuse' of application of topical steroids as they occur in different settings and provides a schematic algorithm for the appropriate and optimal application of topical steroids. Consequently, this separation will allow a more accurate estimation of the burdens of these two aspects that require different solutions. 31-40 (2007) Topical glucocorticoids are the foundation of dermatotherapeutics [1], particularly for the noninfected inflammatory dermatoses, such as the eczemas and dermatitis. Their availability since 1952 has marked the most important milestone in dermatology to date [2,3]. Although the 'ideal' topical steroids have not yet been synthesized, topical administration of steroids still remains the safest mode of administration for glucocorticoids.Topical steroids are derivatives of the prototype hydrocortisone, a natural glucocortico steriod of the adrenal cortex. Chemical substitutions at certain key positions of the cyclopentanophenathrene nucleus, altering both its glucocorticoid and mineralocorticoid properties, affects the potency of these drugs. For example, halogenation at the 9-α position enhances the potency by improving activity within the target cell and decreasing breakdown into inactive metabolites [4], while masking or removing the hydrophilic 17-dihydroxyacetone side chain or the 16 α-hydroxy group increases the lipophilicity of the molecule, thereby enhancing penetration through the stratum corneum [1,5].The existence of a reservoir within the stratum corneum for most topical xenobiotics, particularly topical steroids [6,7], affects the choice of application frequency and the dose, while percutaneous absorption is dependent on the intrinsic property of the steroid, the vehicle used, the anatomical site, age of patient and method of application (i.e., under occlusion or hydration). However, individual variation in percutaneous absorption can also be quite pronounced. All of these factors must be taken into account when considering the potential for undesirable effects of topical steroids.Abuse of steroids could be regarded as the use of steroids to achieve purposes other than a therapeutic one, while misuse of steroids can be regarded as the inappropriate use of steroids for therapeutic purposes. These terms are introduced in this article for the purpose of describing the inapt use of prescr...

Incontinence-Associated Dermatitis: An Insidious and Painful Condition

“…As the development of IAD is driven by an underlying inflammatory process, the use of products containing anti-inflammatory properties is also favored. Topical steroidal products such as hydrocortisone are frequently prescribed for its anti-inflammatory effects on various dermatoses such as IAD [39]. The application of a thick layer of skin protectants is consistently advocated in clinical guidelines, and care providers are cautioned against total removal of leave-on skin products at every diaper change.…”

Crisaborole and its Potential Role in Treating Atopic Dermatitis: Overview of Early Clinical Studies

“…TCS reduce inflammation and pruritus [4,9,16,20,49,62] by acting on various immune cells to disrupt antigen processing and presentation and by suppressing the release of proinflammatory cytokines [4,69,70]. They are frequently prescribed to treat the acute and chronic signs of AD in adults and children [4,49].…”

“…For acute flares, TCS are often used daily for up to several weeks, and proactive use (once to twice weekly) is recommended for chronic relapsing areas [4]. Potential adverse effects of long-term treatment include striae, folliculitis, acne-like eruptions, focal hypertrichosis, allergic contact dermatitis, glaucoma, papilloedema and telangiectasia [4,66,69]. Long-term TCS treatment is associated with an increase in the risk of tachyphylaxis to TCS, and hypothalamic-pituitary-adrenal axis suppression, Cushing syndrome, growth retardation, glucose intolerance, peptic ulcer disease, neuropsychiatric manifestations and other adverse effects [4,66,69].…”

“…The structure of skin in these areas, characterized by a thin epidermis, extensive vascularization or many epidermal appendages and nerve endings, causes it to be more absorbent [20,69]. Therefore, TCS should not be used under occlusion in these areas [4,20,49,67], and patients prescribed TCS should be closely monitored [20,72,73] and educated about proper uses [16].…”

Effect of topical steroid-dependent facial dermatitis on quality of life: A hospital-based cross-sectional study using DLQI

“…Topical corticosteroids (TCs) are the mainstay of dermato-therapeutics. [1] Though they were introduced in 1952, earliest reports of TC dependence or addiction started appearing shortly thereafter within next two decades by 1970s. [23] Due to wide availability of these TCs, there is rampant, dismal, and disturbing misuse of topical steroid on face in India which results in severe cutaneous damage characterized by erythema, monomorphic acne, steroid atrophy, steroid rosacea, telangiectasia, perioral dermatitis, striae, and severe addiction to the TC.…”