Systemic Side-Effects of Topical CorticosteroidsTopical corticosteroid is a term refering to any sort of cream, gel or ointment containing corticosteroids. Topical corticosteroids are female bodybuilding competition diet plan used to treat inflammatory skin conditions such as atopic eczema and psoriasis. Their main purpose is to reduce skin inflammation and irritation. They cannot cure the conditions that trigger these symptoms, but they can provide temporary relief during a particularly bad flare-up of symptoms. Read more about when topical corticosteroids are used can topical steroids increase blood pressure how topical corticosteroids work. For information about steroid tablets and sprays, see our page on corticosteroids.
Topical corticosteroids - jmhw.info
With the introduction of topical corticosteroids, a milestone has been achieved in dermatologic therapy; owing to its potent anti-inflammatory and ant proliferative effects, it became possible to treat some hitherto resistant dermatoses. But this magic drug can cause enough mischief if used inappropriately. Children are more susceptible to the systemic adverse effects because of enhanced percutaneous absorption through their tender skin.
So, systemic side effects should be kept in mind while prescribing this therapeutically valuable topical medicament. Topical corticosteroids are one of the most commonly used topical medicines in dermatology. They are in use for more than 50 years. They were first used successfully by Sulzberger and Witten in [ 1 ] and their success marked a cornerstone in the history of dermatology.
Numerous topical corticosteroids are now available in different preparations, concentrations and potencies. Topical steroids are categorized into seven classes according to their potency. This categorization is based on their vasoconstrictive property.
The goal of topical steroid is to deliver therapeutically effective dosage of the drug to the target organ with least possible side effects mainly the systemic ones. The possibility that these drugs could be percutaneously absorbed was considered soon after they came into use, but in several investigations no definitive evidence of such absorption was found.
Gradually, however, data have accumulated indicating that the steroids can be absorbed through the skin. Percutaneous absorption of topical steroids depends on a number of factors. The stratum corneum acts as a barrier for percutaneous absorption of drug into systemic circulation. The horny layer also serves as a reservoir from which drug penetration into the body continues even after a single application. Fortunately, these side effects are rare, but may sometimes occur, especially in infants[ 4 ] and elderly patients.
This variability of reported adverse effects may be explained by the heterogeneity of patients, the topical steroid studied and the method of assessment used. Percutaneous absorption involves passage of the drug through epidermis, dermis, and into the circulation. Topical medicines have poor total absorption and a very slow rate of absorption and topical steroids are no exception to this.
The stratum corneum acts as the rate-limiting barrier to percutaneous drug absorption. Due to varying thickness of this layer at different body parts, drug penetration also varies at different sites being highest through mucous membrane and scrotal skin and least through palmo-plantar skin.
There are two main routes of permeation through stratum corneum: The transepidermal or transcellular pathway is the most important route. For topically applied drugs, the concentration difference is simply the concentration of drug in the vehicle.
Percutaneous toxicity of topical steroids is directly related to percutaneous absorption, so factors governing percutaneous absorption also influence systemic side effects.
Evaluation of patients suspected to have secondary adrenal failure or HPA axis suppression and Cushing's syndrome may consist of the following tests. An early morning 8 a. This is an excellent diagnostic tool.
This assay is especially useful in patients with hypoalbuminaemia secondary to hepatic impairment and in cirrhosis. This is the preferred method of detecting adrenal suppression. Plasma cortisol levels are obtained at 0, 30 and 60 minutes. This test evaluates the entire HPA axis and is capable of assessing partial and recent onset adrenal suppression.
This test is limited by the associated risk of hypoglycemic seizures and must be performed under supervision. This provocative test also examines the status of the entire HPA axis. The advantage of this assay over ITT is its safety and convenience. In addition to local side effects, prolonged use of topical steroids can cause systemic side effects which are less common than those due to systemic corticosteroids. These occur especially in infants and elderly patients. The documented adverse effects are:.
Exogenous glucocorticoids even in topical form have suppressive effects on hypothalamic cortisol releasing hormone and pituitary adrenocorticotropic hormone ACTH. With prolonged use, suppression of HPA axis and adrenal insufficiency with adrenal gland atrophy can occur, and it takes months to recover fully after treatment discontinuation. The increased blood level of glucocorticoids can also induce features of hypercortisolism or iatrogenic Cushing's syndrome such as diastolic hypertension, diabetes, buffalo hump, facio-troncular obesity, hirsutism, striae, telangiectasia, skin fragility etc.
According to the existing literature, over the last 35 years, more than 40 around 43 cases of iatrogenic Cushing's syndrome have been documented. Most commonly used steroid in both the groups was Clobetasol propionate 0. The median duration of application was 2. The mean recovery period of HPA axis suppression was 3. The use of Clobetasol propionate 0. In some studies, it has been shown that even a much less amount of topical steroid can induce systemic adverse effects; this may be due to the use of occlusion.
Cushing's syndrome was also reported with the use of relatively low potent topical steroid triamcinolone acetonide 0. The existing literature regarding HPA axis suppression is somewhat controversial, especially in the case of adults. Some workers have noted normal or clinically insignificant suppression of the HPA axis during treatment with topical steroids.
In most of the short-term studies, plasma cortisol level was mainly recorded early in the course of therapy; and the value returned to normal with recovery of HPA axis function within weeks suggesting that the restoration of epidermal barrier function resulted in reduced percutaneous absorption. The reported variability of HPA axis status with topical corticosteroid therapy may be because of the heterogeneity in study groups and topical steroids studied and method of assessment used to assay the HPA axis function.
Growth impairment has been reported in an infant treated with betamethasone valerate 0. Prolonged use of topical steroids on the eyelid can induce open-angle glaucoma and cataract from transpalpebraltarsal penetration. Death due to disseminated cytomegalovirus infection in two infants is the dreaded complication reported yet. In both the cases, clobetasol propionate was the culprit agent.
National Center for Biotechnology Information , U. Journal List Indian J Dermatol v. Received May; Accepted May. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC. Abstract With the introduction of topical corticosteroids, a milestone has been achieved in dermatologic therapy; owing to its potent anti-inflammatory and ant proliferative effects, it became possible to treat some hitherto resistant dermatoses.
Adverse effects , hypothalamus-pituitary-adrenal axis , infants and children , percutaneous absorption , topical corticosteroids.
Topical steroids can be absorbed through the skin. Even small doses of potent topical steroids can produce systemic side effects particularly in children and the elderly. Diseased skin has impaired barrier function resulting in enhanced percutaneous absorption and systemic side effects.
Introduction Topical corticosteroids are one of the most commonly used topical medicines in dermatology. Percutaneous Absorption of Topical Steroids Percutaneous absorption involves passage of the drug through epidermis, dermis, and into the circulation. Age of the patient: Young children have greater surface area to volume ratio and are less able to metabolize the drug quickly and adequately. Body site and area treated: Penetration of the drug correlates inversely with the thickness of the stratum corneum; drug penetration is highest through mucous membrane and scrotal skin and least through palmo-plantar skin.
Amount of topical steroid used: Absorption is directly proportional to the mass or concentration of topical steroid applied to the skin up to a critical point. Structure and Potency of the drug: Higher the potency, increased is the chance of systemic side effects. Structural modification alters the lipophilicity and solubility of a molecule and hence its absorption. It also affects the biotransformation of the active molecule. Vehicle of the drug: Vehicle is one of the factors which determine the partition co-efficient, Km and hence percutaneous transport.
Solvents such as propylene glycol and ethanol result in an increased permeability after prolonged use. Repeated application increases the contact period and thus total absorption. Occlusion via any means increases the hydration and temperature of stratum corneum and thus enhances drug penetration.
Nature of the diseased skin: The skin condition also affects bioavailability. Diseases with impaired barrier function like atopic dermatitis or Netherton syndrome have been associated with enhanced penetration. Coexistent hepatic and renal disease: The glucocorticoids are metabolized mainly in the liver by CYP 3A4 and excreted through kidneys.
Concomitant use of other drugs which are potent inhibitors of CYP 3A4 also increases the risk of systemic side effects. Dimethyl sulfoxide causes superhydration of stratum corneum with subsequent enhanced permeability[ 13 ]. Local hyperemia may cause an increase in flux.
Vigorous rubbing into the skin increases the surface area of skin covered and local blood supply and thus augmenting systemic absorption. Investigation Protocol Evaluation of patients suspected to have secondary adrenal failure or HPA axis suppression and Cushing's syndrome may consist of the following tests. Basal cortisol level measurement An early morning 8 a. Midnight or nocturnal salivary cortisol level This is an excellent diagnostic tool.
ACTH stimulation test This is the preferred method of detecting adrenal suppression. Insulin tolerance test ITT This test evaluates the entire HPA axis and is capable of assessing partial and recent onset adrenal suppression. Metyrapone test This provocative test also examines the status of the entire HPA axis.