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The Only Three Topical Steroids That Nondermatologists Need


 

EXPERT ANALYSIS FROM A SYMPOSIUM SPONSORED BY THE AMERICAN COLLEGE OF RHEUMATOLOGY

SNOWMASS, COLO. – Unless you’re a dermatologist, you’re likely to need just three topical corticosteroids from the dizzying array of available products.

That’s the contention of Dr. Ruth Ann Vleugels, a dermatologist who is director of the connective tissue disease clinic at Brigham and Women’s Hospital in Boston and codirector of the rheumatology-dermatology clinic at Children’s Hospital Boston. She advises gaining familiarity with the use of desonide, triamcinolone 0.1%, and clobetasol.

"Honestly, this is 90% of what I use. If you have a ‘favorites’ tab on your [electronic health record system] you can plug in these three with their instructions and you’ll never need to use any other topical steroids," she said at the conference.

Clobetasol is a potent steroid, triamcinolone 0.1% is midstrength, and desonide is lower-potency. Clobetasol and triamcinolone 0.1% are generally utilized for skin disease on the body, whereas desonide is the appropriate choice for skin disorders on the face, groin, axillae, and breasts.

Many nondermatologists are leery about long-term topical corticosteroid therapy. But there’s no need for concern as long as the drugs are used with breaks, Dr. Vleugels emphasized.

"You can use topical steroids for life with no issues; we know that from studies in our psoriasis and eczema patients. But we can’t use them without breaks. That’s the most important message in counseling your patients. For the body, it’s 2 weeks on, 1 week off. For the face, it’s 1 week on, 1 week off. If they do that, you won’t see steroid side effects," she said.

The side effects that are seen with uninterrupted topical steroid therapy include skin atrophy, striae, lightening, and telangiectasias.

When desonide is used in treating the groin, breasts, or armpits, the schedule is 1 week on, 1 week off – the same as the facial schedule.

Dr. Vleugels makes an exception to these rules when she’s treating facial lesions related to autoimmune diseases. Because she wants to get rapid clearing, she often turns to a burst of clobetasol in these circumstances. The schedule is 1 week on, 1 week off.

"A typical situation might be when a rheumatologist calls me and says, ‘I have a patient who got a horrible photosensitive malar rash while outdoors last weekend, and she’s already on maximum-dose systemic therapy.’ I’d say, just give her 1 week of clobetasol on her face; she’ll be better in 3-4 days. But you need to carefully tell your patients that if they’re going to put it on their face they have to follow the rule for face disease: 1 week on, 1 week off," she said.

Cream or ointment? For most patients with autoimmune diseases, pick a topical steroid cream; it’ll result in better compliance. A steroid ointment is preferable when skin hydration is a consideration, as in atopic dermatitis. Because ointments are effectively stronger and more deeply penetrating than creams, a steroid ointment is also the best choice in treating disease involving particularly thick skin, such as palmar or plantar psoriasis, where the medication is employed under occlusion with gloves or socks, Dr. Vleugels explained.

To avoid undertreatment, it’s important to specify on the prescription how much medication the pharmacy is to provide. A 60-g tube of a topical steroid won’t last longer than a week in a patient with a full-body skin eruption; Dr. Vleugels generally orders 120-240 g for such patients. For patients treating lesions on the face or other sensitive areas, she cuts the prescription to 30 g with a single refill unless she’s comfortable with that individual’s adherence.

Topical calcineurin inhibitors have a limited role. Dr. Vleugels considers using 0.3% tacrolimus during patients’ week-long topical steroid breaks if their disease isn’t well controlled during those intervals. She also considers tacrolimus in patients with periorbital skin lesions, where steroid atrophy is a particular concern. Topical pimecrolimus is considerably less effective than tacrolimus, and she never uses pimecrolimus in adults.

"I use these agents much less frequently than topical steroids. They’re often low efficacy for the cost [compared with] a topical steroid, used safely," the dermatologist said.

She reported having no financial conflicts.

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