Transcript Slide 1
Topical Steroid Therapy Val Anderson Dermatology Specialist Nurse South Gloucestershire Community Health Services What are steroids? • Essentially hormones • Glucocorticoids/ mineralcorticoids • Naturally formed in the adrenal cortex • Natural glucocorticoids maintain normal blood sugar and assist the body to recover in times of stress. Why Topical Steroids ? • To gain control of signs and symptoms of inflammatory skin disease • Achieve maximum efficacy with minimal side effects. Action of Topical Steroids • Anti-inflammatory • Immunosuppressive • Vasoconstrictive • Anti-mitotic – decrease proliferation • Readily penetrate the dermis “Reduce inflammation and make the skin less sore and itchy” Steroid Phobia • Present in health care professionals, patients and carers. • A reluctance to use prescribed topical steroids due to perceived side effects • Reassurance is essential to gain full concordance with treatment. REMEMBER: Appropriate topical steroid use limits potential side effects almost entirely. Potential side effects Cutaneous Thinning / Atrophy Hypopigmentation Striae Telangietasia Tachyphylaxis, Infections, Perioral dermatitis, Contact dermatitis, Hirsutism, Monomorphic acne or rosacea N.B Epidermal thinning does occur within 1-3 weeks of tx with potent or very potent steroids normal skin but reverses within 4 weeks of stopping Potential Side Effects : systemic • These are RARE and ALWAYS AVOIDABLE • Due to systemic absorption of the steroid Adverse effects : systemically • • • • • • • Osteoporosis Muscle atrophy Cushings Syndrome Inhibition of growth (children) Cataracts Masking of infection Hypoglycaemia Which steroid?- factors to consider • Age /potency – adult, adolescent or child • Site – absorption increased at certain sites • Extent- localised or generalised • Base- creams or ointments? • Method- frequency of application / occlusion • Experience of use - dexterity Steroid potencies • Group I. • Group II. • Group III. • Group IV. Mild e.g. Hydrocortisone 1% OTC (over the counter) Mod (1 X OTC) Potent prescription only Very potent prescription only Relative potencies compared to Hydrocortisone 1% (Grp I) • Group 2 - 2.5 x stronger • Group 3 - 10 x stronger • Group 4 - 50 x stronger Steroid ladder VERY POTENT Dermovate Nerisone Forte POTENT Synalar Fucibet Diprosalic Betnovate Elocon Locoid MODERATELY POTENT Eumovate Haelan Trimovate Calmurid HC Betnovate RD Synalar 1 in 4 MILD Hydrocortisone 0.5%,1.0% & 2.5% Fucidin H Alphosyl HC Synalar 1 in 10 Steroid application • Reassure - explain rationale for use and benefits • Early use - to control exacerbations • Therapeutic dose - < prolongs flare and subsequent control • Demonstrate - light smear, F.T.U (finger tip unit) Weekly Quantities of steroid Adult using b.d applications Creams and Ointments • face & neck…………………… 15 - 30g • both hands…………………… 15 - 30g • scalp………………………….. 15 - 30g • both arms…………………….. 30 - 60g • both legs……………………… 100g • trunk…………………………... 100g • groins & genitalia……………. 15 - 30g BNF March 2006 Summary of NICE Guidelines • No statistical difference between once and twice daily steroid applicaton frequency on efficacy. • Application 10-14 days and consider steroid holiday • Improve patient and carer education Steroid Workshop •Practice finger tip unit measurements •Discuss photos and case studies Case Study 1 • 6 month old baby with history of eczema since 4 • • • months old. Tried emollients and has been given topical steroids by GP 2 weeks ago. O/E moderate eczema present on facial cheeks. Excoriations present and baby waking at night. Not improved since prescription for topical steroid given. What issues related to topical steroid use would you consider during assessment and treatment decisions for this child ? Case Study 2 • 14 year old boy • History of eczema since 2 years old. • O/E has moderate levels of eczema in arm flexures with some weeping. • Prescribed hydrocortisone 1% ointment by GP 3 weeks ago- nil improvement. • Arms now becoming sore. What issues related to topical steroid use would you consider during assessment and treatment decisions for this child ? Any Questions ? I have one for you What will you do differently tomorrow?