34 / 36
34
SKIN CARE TODAY
2016,Vol 2, No 1
TOP TIPS
i
i
Creams: these may be more
cosmetically acceptable and on
wet and weepy skin, they can
help to dry the skin. They are
also used for their cooling and
moisturising effects.
i
Gels: these may be better for
use on hairy areas and may be
more cosmetically acceptable
to patients, especially when
used in the scalp.
i
Alcohol-based preparations
may sting the scalp or skin, so
patients should be warned as
this may cause irritation.
i
How much to apply: although
some topical corticosteroids
are now available in pump
dispensers which enable
measured amounts to be
applied, a fingertip unit (FTU)
helps with accuracy. A FTU is
about 500mg, and should be
enough to treat an area of skin
double the size of the flat of
the hand with fingers together
(
Figures 1
and
2
).
i
Application method: once
to twice daily depending on
the preparation and site of
application. Apply to a shine
and smooth into the skin in
the direction of hair growth
(usually downwards).
i
Duration of application is
important: one to two or three
weeks may be adequate, and
steroid ‘holidays’ should be
advised with longer term use.
i
Tachyphylaxis (decreased
response as a result of a
medication being applied
multiple times; http://
eczemag.com/facts-of-topical-
corticosteroids) can develop,
so prescribers should taper
patients off these topical
treatments. If patients need
longer treatments, topical
pulsed therapy after a one-
week steroid-free period
may help, and reduces
rebound effects.
i
Topical corticosteroid side-
effects: these can include
atrophy (skin thinning),
collagen loss, opportunistic
infections, purpura (rash —
purple spots — caused by
bleeding into the skin from
capillary blood vessels), striae
(stretch marks), telangiectasia,
perioral dermatitis (rash
around the mouth/lower
half of the face), and
rosacea exacerbations.
i
To minimise side-effects of
a topical corticosteroid, it is
important to apply it thinly to
affected areas only, no more
frequently than twice-daily,
and to use the least potent
formulation which is fully
effective (BNF 70,
September 2015).
i
More potent topical
corticosteroids should be
avoided for skin around the
eyes and eyelids, as this area
is especially thin and more
vulnerable, thus increasing the
risk for adverse events.
i
Avoid prolonged use of a
topical corticosteroid on the
face (BNF 70, September
2015).
i
Potent corticosteroids should
generally be avoided on the
face and skin flexures, but
specialists do occasionally
prescribe them for use
on these areas in certain
circumstances (BNF 70
September 2015).
i
Occlusion: applying a
topical corticosteroid and
then occluding it with a film
dressing, increases its potency.
However, this should only be
done by specialists or those
experienced in occlusion
therapy, as side-effects are
likely to occur.
i
Give clear instructions: this
is vital, as patients may
misunderstand instructions
Figure 2.
Fingertip unit (FTU).
from prescribers. Remember,
too little topical steroid may
not give a response, while too
much increases the risk of
adverse effects.
i
The written management plan
is a good idea with potencies
identified, site for use,
frequency of application and
duration for use documented
to avoid confusion/error.
i
Steroid phobia: the risks
of steroid atrophy should
be discussed at the outset,
yet reassurance about how
effective and safe topical
steroids are when used
correctly is important.
i
Topical corticosteroids are
contraindicated in untreated
bacterial, fungal, or viral skin
lesions, in acne, rosacea, and
in perioral dermatitis.
i
There are a variety of topical
corticosteroids for use on the
body, the scalp, the flexural
areas, the face and the genital
skin. Most preparations come
in 30g, 50g, and or a 100g tube.
i
The following list is not
exhaustive, but identifies some
of the common preparations
used in practice. The BNF
2015/2016 has the latest up-
to-date listings of preparations
by both brand and generic
name and highlights licence
for use and potency ratings.