Topical corticosteroids are used for the symptomatic relief of inflammatory dermatoses. The cause of the dermatoses should be determined and eliminated if possible; dermatoses are controlled but not cured by these drugs. Although systemic corticosteroids are more effective in most dermatologic inflammations, topical treatment is preferred in most responsive cases because it causes fewer adverse systemic effects.
Topical corticosteroids generally are most effective in the treatment of acute or chronic dermatoses such as seborrheic or atopic dermatitis, localized neurodermatitis, anogenital pruritus, psoriasis, and the inflammatory phase of xerosis. Topical corticosteroids are effective in the late phase of allergic contact dermatitis or irritant dermatitis, but systemic corticosteroids are usually required to relieve the acute manifestations of these dermatoses.
Individual topical corticosteroid preparations vary in anti-inflammatory activity (as measured by vasoconstrictor assay) and in percutaneous penetration, but therapeutic efficacy of a particular drug can often be increased by increasing the concentration or by using occlusive dressing therapy. As with systemic use, some patients may respond better to one topical corticosteroid than to another. Topical corticosteroid preparations may be grouped according to relative anti-inflammatory activity, but activity may vary considerably depending upon the vehicle, the site of application, disease, the individual patient, and whether or not an occlusive dressing is used.
(See Pharmacokinetics.)Approximate relative activity (based principally on vasoconstrictor assay and/or clinical effectiveness in psoriasis) of some topical corticosteroid preparations in decreasing order is as follows (preparations in each group are approximately equivalent): Group I Betamethasone dipropionate (Diprolene) cream (optimized vehicle) or ointment (optimized vehicle) 0.05% (of betamethasone) Betamethasone dipropionate (Diprolene AF) cream 0.05% (of betamethasone) Clobetasol propionate (Clobex, Temovate, Olux) cream, foam, ointment, lotion, or shampoo 0.05% Diflorasone diacetate (Psorcon) ointment (optimized vehicle) 0.05% Group II Amcinonide (Cyclocort) ointment 0.1% Betamethasone dipropionate (Diprosone) ointment 0.05% (of betamethasone) Desoximetasone (Topicort) cream or ointment 0.25% Desoximetasone (Topicort) gel 0.05% Diflorasone diacetate (Florone, Maxiflor) ointment 0.05% Fluocinonide (Lidex) cream or ointment 0.05% Fluocinonide gel 0.05% Halcinonide (Halog) cream 0.1% Group III Betamethasone benzoate gel 0.025% Betamethasone dipropionate (Diprosone) cream 0.05% (of betamethasone) Betamethasone valerate (Valisone) ointment 0.1% (of betamethasone) Diflorasone diacetate (Florone, Maxiflor) cream 0.05% Mometasone furoate (Elocon) ointment 0.1% Triamcinolone acetonide (Aristocort) cream 0.5% Group IV Desoximetasone (Topicort LP) cream 0.05% Fluocinolone acetonide (Synalar-HP) cream 0.2% Fluocinolone acetonide (Synalar) ointment 0.025% Flurandrenolide (Cordran) ointment 0.05% Triamcinolone acetonide (Aristocort, Kenalog) ointment 0.1% Group V Betamethasone benzoate cream 0.025% Betamethasone dipropionate (Diprosone) lotion 0.05% (of betamethasone) Betamethasone valerate (Valisone) cream 0.1% (of betamethasone) Betamethasone valerate (Valisone) lotion 0.1% (of betamethasone) Fluocinolone acetonide (Synalar) cream 0.025% Flurandrenolide (Cordran) cream 0.05% Hydrocortisone butyrate (Locoid) cream 0.1% Hydrocortisone valerate (Westcort) cream 0.2% Prednicarbate (Dermatop Emollient) cream 0.1% Triamcinolone acetonide (Kenalog) cream 0.1% Triamcinolone acetonide (Kenalog) lotion 0.1% Group VI Alclometasone dipropionate (Aclovate) cream or ointment 0.05% Desonide (Tridesilon) cream 0.05% Fluocinolone acetonide (Synalar) solution 0.01%
Although some dermatoses may require therapy with a relatively more active corticosteroid initially, treatment with hydrocortisone, dexamethasone (a topical preparation is no longer commercially available in the US) , methylprednisolone, or prednisolone, which are generally considered to be less active (i.e., Group VII) than preparations in groups I-VI, is often sufficient and is less likely to cause adverse reactions. Although fluorinated corticosteroids are generally more biologically active and have greater antimitotic activity than nonfluorinated drugs, fluorination is not essential for increased anti-inflammatory activity (e.g., hydrocortisone valerate has more topical anti-inflammatory activity than does betamethasone or dexamethasone). Relatively more active corticosteroids with or without occlusive dressing therapy are used for severe or resistant dermatoses such as psoriasis and chronic neurodermatitis. Dermatoses such as discoid lupus erythematosus, lichen planus, granuloma annulare, and psoriasis of palms, soles, elbows, and knees or psoriatic plaques usually require topical corticosteroids with increased anti-inflammatory activity and occlusive dressings or intralesional or sublesional corticosteroid injections. Hypertrophic lichen planus, alopecia areata, hypertrophic scars, and keloids generally require intralesional corticosteroid therapy.
Ulcerative Colitis and Anorectal Disorders
Hydrocortisone is used as a retention enema in the adjunctive treatment of mild or moderate acute ulcerative colitis limited to the rectosigmoid or left colon and, to a lesser extent, in some patients with mild acute ulcerative colitis of the transverse or descending colon. Corticosteroid enemas are usually effective in patients with mild or moderate acute ulcerative colitis of the rectosigmoid who do not adequately respond to sulfasalazine alone or in whom sulfasalazine cannot be given; sulfasalazine is generally considered the drug of choice for maintenance therapy in mild or moderate ulcerative colitis. Systemic corticosteroids and/or corticosteroid enemas are more effective than sulfasalazine in acute attacks of ulcerative colitis but, if surgery is required, it should not be delayed in favor of corticosteroid therapy.
Hydrocortisone acetate, as rectal suppositories or a suspension (foam), may be effective in the adjunctive treatment of ulcerative colitis of the rectum. As rectal suppositories, hydrocortisone acetate is also used in the treatment of other inflammatory conditions of the anorectum (e.g., inflamed hemorrhoids, postirradiation or factitial proctitis, cryptitis, pruritus ani).
Preparations containing a corticosteroid and local anesthetic may be useful in the symptomatic relief of anorectal disorders such as hemorrhoids, but commercially available corticosteroid combinations with antihistamines, astringents, keratolytics, and/or vasoconstrictors are of questionable efficacy.
Topical corticosteroids are commercially available in combination with antibiotics such as neomycin and antifungals such as clioquinol (iodochlorhydroxyquin). Results of some well-controlled clinical studies using cortisol suggest that these combination preparations are more effective than either the corticosteroid or anti-infective agent alone in infected dermatoses. Combined therapy with triamcinolone and nystatin has been shown to be more effective than nystatin alone for improving the clinical severity of cutaneous candidiasis, especially during the first few days of therapy; combined therapy generally provides earlier relief of signs and symptoms of this infection than does nystatin alone. If topical corticosteroids are used in combination with topical anti-infective agents, the benefit must be weighed against the risk of contact sensitization to the anti-infective agent and suppression by the corticosteroid of manifestations of infection.
(See Cautions: Precautions and Contraindications.)
For EENT uses of corticosteroids, . For systemic and intralesional uses of corticosteroids,