One of the most important skills in the treatment of skin disorders is the use of topical and intralesional steroids. The number of allergic, inflammatory, and immunologic skin diseases that respond to topical and intralesional steroids is vast. However, the indiscriminate use of topical steroids on unknown skin disorders can result in problems such as skin atrophy, telangiectasias, or tinea incognito (a condition caused by the incorrect application of topical steroids to a fungal infection, allowing the tinea to worsen). (See Chapter 144, Tinea Corporis.) Some of the types of skin diseases in which topical steroids are effective include:
Allergic skin diseases including atopic dermatitis, contact dermatitis, and hand eczema.
Papulosquamous conditions including psoriasis, lichen planus, and seborrheic dermatitis.
Connective tissue diseases of skin including lupus.
Autoimmune bullous disease including pemphigus.
Infiltrative and immunologic diseases including sarcoidosis and granuloma annulare.
Learning to use topical steroids effectively requires understanding the range of potencies, the vehicles available, and the amounts needed for acute and chronic skin conditions. It is also essential to understand the possible adverse reactions and to be able to balance those risks against the benefits of topical and intralesional steroids. The common side effects are listed in Table 112-1.
TABLE 112-1Common Side Effects of Topical Corticosteroids |Favorite Table|Download (.pdf) TABLE 112-1Common Side Effects of Topical Corticosteroids
|Skin atrophy || |
Most common adverse effect
Epidermal thinning may begin after only a few days
Dermal thinning usually takes several weeks to develop
Usually reversible within 2 months after stopping the corticosteroid
|Telangiectasia || |
Most often occurs on the face, neck, and upper chest
Tends to decrease when steroid discontinued, but may be irreversible
|Striae || |
Usually occur around flexures (groin, axillary, and inner thigh areas)
Usually permanent, but may fade with time
|Purpura || |
Frequently occurs after minimal trauma
Attributed to loss of perivascular supporting tissue in the dermis
|Hypopigmentation ||May be reversible upon discontinuing the corticosteroid |
|Acneform eruptions || |
Particularly common on the face, especially with the "potent" and "very potent" corticosteroids
|Fine hair growth ||Reversible upon discontinuation of the corticosteroid |
|Infections || |
May worsen viral, bacterial, or fungal skin infections
May cause tinea incognito
|Hypothalamic–pituitary–adrenal axis suppression || |
Rare with topicals
>30 g/week of "very potent" corticosteroids should be limited to 3 to 4 weeks
Children (>10 g/week) and elderly are at higher risk because of thinner skin
Topical steroids have a wide range of potency (Table 112-2). Choosing the correct potency is the first step in prescribing a topical steroid. The most important factors to consider are:
Location—area of the skin involved. Skin atrophy is more likely in areas of thin skin such as the face, the genitalia, and the intertriginous areas. Therefore, lower potency steroids are preferentially used on the face and in the intertriginous areas.
Diagnosis—some conditions such ...