High Potency Topical Steroids Research Articles

Lichenoid drug reaction to antituberculosis drugs treated through with topical steroids and phototherapy

Lichenoid drug reaction to antituberculosis drugs treated through with topical steroids and phototherapy

국소부신피질호르몬제 사용 중단 후 나타난 홍피성 건선의 한방 치험 1례

Objective : The aim of this study is to report the effect and safety of Traditional Korean Medicine on the treatment of erythrodermic psoriasis which appeared after stopping high potency topical steroids. Methods : A patient with psoriasis stopped topical steroids after the first outpatient care and was treated with herbal medicine, acupuncture, moxibustion for eight months. The severity of psoriasis was assessed with Psoriasis Area and Severity Index. Liver and renal functions were tested to observe the hepatic and renal toxicity of the treatment. Results : PASI score were 6.2 on the first visit and three months after it increased to 30 and the patient showed symptoms of erythrodermic psoriasis. And seven months after the first visit, it decreased to 0.6. There was no hepatic and renal toxicity of the treatment. Conclusion : These findings suggest that Traditional Korean Medicine might be effective and safe for the treatment of erythrodermic psoriasis.

Striae atrophicans: A mimic to Cushing′s cutaneous striae

Sir, A 30-year-old male patient was referred for evaluation of Cushing's syndrome when he presented with purple striae over both the thighs [Figure 1] for 1 month. He did not have any systemic symptoms. There was no history of any drug intake including oral or parenteral steroids. He was applying steroid ointment (halobetasol propionate 0.05%) for fungal infection locally for 3 months prior to this. These striae were violaceous, with the largest one measuring 10 cm in length and 1.8 cm in width, which is classical for Cushing's syndrome. His body mass index was 26.0 kg/m2. He did not have any systemic effects of steroid, though human and animal studies indicate that less than 6% of the applied dose of halobetasol propionate enters the circulation within 96 hours following topical administration of the cream.[1] His morning and evening cortisol levels were 10.65 μg/dL and 5.28 μg/dL, respectively. Overnight dexamethasone test revealed suppressible serum cortisol (0.55 μg/dL). Halobetasol propionate cream produced hypothalamic-pituitary-adrenal (HPA) axis suppression when used in divided doses at 7 g/day for 1 week.[2] His serum cortisol level following adrenocorticotropic hormone (ACTH) stimulation test was 25.6 μg/dL. He was diagnosed as a case of striae atrophicans, which is a known complication of chronic application of topical steroid preparations. Halobetasol is grouped under ultra high potency topical steroid and has more propensity to cause side effects. The glucocorticoids affect the epidermis by preventing the fibroblasts from forming collagen and elastin fibers, necessary to keep the rapidly growing skin taut. This creates a lack of supportive material, as the skin is stretched and leads to dermal and epidermal tearing.[3] Topical application of steroids is known to cause systemic effects of hypercortisolism and suppression of HPA axis, but this is very rarely manifested clinically and is easily reversible. This patient has neither any systemic manifestation nor any evidence of adrenal suppression. Figure 1 Multiple cutaneous striae at thigh

An Unfamiliar “Common” Skin Disease: Poison Ivy Allergic Contact Dermatitis

We present a case of phytodermatitis caused by a poisonous plant known as poison ivy. It is one of the leading causes of allergic contact dermatitis and it causes significant morbidity in the United States. Prevention of the disease is by identification and avoidance of the plant. Barrier protection minimises the chance of contact and prompt rinsing with soap water limits antigen exposure after skin contact. General approach to treatment of allergic contact dermatitis can be applied but special precaution should be taken on the duration of systemic steroid therapy. Too short a course of oral steroid may result in a more severe recurrent flare. High potency topical steroids may limit the development of skin lesions. (Hong Kong j.emerg.med. 2011; 18:335-338)

Pruritic urticarial papules and plaques of pregnancy wholly abated with one week twice daily application of fluticasone propionate lotion: A case report and review of the literature

Pruritic urticarial papules and plaques of pregnancy (PUPPP) is among the most common dermatoses of pregnancy. Most reports of the effective treatment of PUPPP involve high potency topical corticosteroids or oral steroids. Many authorities have noted cases of PUPPP whose resolution followed parturition. A few have noted that PUPPP can arise and resolve the third trimester. A 36-year-old prima gravida at 38 weeks of gestation presented with a 2-week history of a pruritic papular abdominal eruption. She used fluticasone propionate 0.05 percent lotion twice a day. One week after starting this medication, the pruritus had resolved and the erythema/urticaria had abated; the pigmentary alteration had improved, but still remained. The PUPPP did not return after parturition. PUPPP can abate entirely during pregnancy. Fluticasone propionate 0.05 percent lotion, a class 5 (low-medium potency) corticosteroid, has a benign side effect profile and should be considered for the treatment of PUPPP during pregnancy.

Chronic atrophic erosive dermatosis of the scalp and extremities: A recharacterization of erosive pustular dermatosis

Erosive pustular dermatosis (EPD) is a rarely reported condition that primarily involves the actinically damaged scalp of elderly women. Although the condition is well recognized in the United Kingdom and Europe, no US cases have heretofore been reported. We sought to document the presence, and determine the clinical characteristics, of EPD in the US population. Patients were recruited from the dermatology clinic at a university in California and from the private practices of dermatologists in the Northern California region. Eleven patients with EPD were identified. Eight were women and 3 were men. The scalp was involved in 9 patients and the extremities in two patients. The involved skin was actinically damaged in 9 patients. The patients were elderly (66-90 years) but one patient was a 15-year-old boy. All lesions resolved or greatly improved with the application of high-potency steroids or tacrolimus. Not all patients were examined personally by the authors of this article. The length of follow-up was relatively short. EPD is a fairly common disease and is the most likely diagnosis in instances where chronic, nonhealing, shallow erosions occur on actinically damaged, or otherwise atrophic, skin. In spite of the name, intact pustules are rarely present. The histology is that of moderate to marked, nonspecific chronic inflammation. EPD responds well to high-potency topical steroids.

Annular atrophic lichen planus

A 30-year-old woman presented with a 1-year history of a pruritic eruption on the extremities, characterized by several annular plaques. The patient had been treated unsuccessfully with medium-potency topical steroids. The lesions had an erythematous papular border with an atrophic center (width, 1-4 cm) (Fig. 1). No oral, genital, or nail lesions were observed. A skin biopsy from one of the plaques was performed. Histopathologic examination of the raised border showed hyperkeratosis of the stratum corneum, focal thickening of the granular layer, basal liquefaction degeneration of the epidermis, and a band-like subepidermal infiltration with numerous Civatte bodies. In the center of the lesion, the epidermis became thinner (Fig. 2). Elastic fibers were reduced or absent in the papillary dermis. The patient was treated with high-potency topical steroids for 2 months with clinical improvement.

Clobetasol Ameliorates Aphthous Ulceration in Renal Transplant Patients on Sirolimus

Aphthous ulceration is a common side effect of sirolimus. These lesions of the oral mucous membranes are often painful and debilitating, leading to either dose reduction or discontinuation of sirolimus in a significant number of patients. We report that the direct application of clobetasol, a high potency topical steroid, led to prompt resolution of the aphthous ulcers that developed in our renal transplant patients on sirolimus-based immunosuppression.

Clobetasol propionate foam in the treatment of psoriasis

Psoriasis is a common, chronic, distressing skin disorder that frequently affects the scalp, skin, nails and joints. Despite treatment, many patients suffer from unremitting disease and decreased quality of life. Scalp-type psoriasis is particularly difficult to treat. Although topical corticosteroids are the mainstay of therapy for moderate-to-severe disease, patients frequently object to the messiness and unfavourable cosmetic appearance of topical treatments. In this context, foam vehicles, which have the advantage of minimal residue and increased ease of application, have emerged as novel alternatives to traditional creams, ointments and solutions. Clobetasol propionate foam 0.05% (OLUX™, Connetics Corporation), a high potency topical steroid, has been shown to alleviate symptoms of several dermatological conditions, including scalp and body psoriasis, improve disease severity and increase quality of life. Dose should be limited to 50 g/week, given the risk of adrenal suppression. Because patient preference is an important determinant of medication efficacy in clinical practice, clobetasol foam is a useful new formulation in the treatment of psoriasis and other skin conditions.

Successful treatment of Zoon’s vulvitis with high potency topical steroid

Zoon's vulvitis is a rare, chronic condition of the vulva that presents with burning, pruritus, and dysuria with characteristic lesions and histopathology. Several treatment options have been reported with limited success. A 63-year-old woman with Zoon's vulvitis diagnosed on histopathology was treated with clobetasol propionate 0.05%. Complete resolution of her symptoms and lesions occurred in less than 1 week. No recurrence of her symptoms has occurred after 9 months. Zoon's vulvitis may be successfully and expeditiously treated with high potency topical steroids.

Necrolytic Acral Erythema

A 46‐year‐old hepatitis C‐positive African American woman presented with a several month history of worsening, well‐marginated, erythematous, dusky plaques on the dorsum of her feet and ankles. After an initial skin biopsy showed spongiotic dermatitis, she was treated with emollients, high potency topical steroids, and keratolytics, all of which were of no benefit. A punch biopsy from the dorsum of her foot showed acanthosis, individual keratinocyte necrosis, confluent upper epidermal necrosis, and a superficial and deep perivascular lymphocytic infiltrate. Given the patient's positive hepatitis C status and clinicopathological correlation, a diagnosis of necrolytic acral erythema was rendered. Empiric therapy with oral zinc sulfate was initiated despite a normal plasma zinc level, and the skin lesions resolved with post‐inflammatory hyperpigmentation. Necrolytic acral erythema, considered one of the necrolytic erythemas, is a cutaneous manifestation of hepatitis C virus infection. A total of nine cases have been reported in the literature, seven from Egypt and two from the United States. All reported patients have been hepatitis C positive. This case represents the third reported patient from the US with necrolytic acral erythema.

Dermoscopic assessment of long-term topical therapies with potent steroids in chronic psoriasis

We investigated the value of the dermoscope for monitoring the long term safety of high potency topical steroids in patients with chronic psoriasis. We observed for the first time that the overuse of topical steroids resulted in the appearance of clinically unapparent but dermoscopically apparent "red lines" (linear telangiectasias) in the treated plaques and/or skin adjacent to the treated plaques (P < .03). We concluded that dermoscopy may help reveal the early signs of impending steroid-induced atrophy ("red lines") before they become clinically evident with the naked eye and before the atrophy becomes permanent.

Pinch skin grafting for idiopathic inflammatory medial meatal fibrotizing otitis

Objectives: Idiopathic inflammatory medial meatal fibrotizing otitis is an uncommon disorder of the external auditory canal characterized by desquamation of the medial canal skin, chronic inflammation, and eventual canal stenosis. Medical treatment consists of regular debridement, topical and systemic steroids, and antimicrobials for acute infections. Surgical treatment of canal stenosis by removal of the fibrotic plug followed by split thickness skin grafting has been reported. However, skin grafting of the canal prior to development of complete stenosis has not been reported. Methods: Case report of a 72-year-old male hearing aid user who was referred for a 7-month history of recurrent external otitis and subsequent stenosis of the external auditory canals. On physical exam, he had erythema, granulation tissue, and synechia in the medial external auditory canals bilaterally. Treatment consisted of regular debridements, external canal wicks, high potency topical steroids, oral steroids, ear powder, and systemic and topical antibiotics. After 20 months of medical treatment, the external canals remained patent but failed to epithelialize. Pinch skin grafts from the posterior auricular area were applied to the medial canal tissue in the office under local anethesia. Results: After 6 weeks, the skin grafts have become adherent to the medial canal tissue and are beginning to epithelialize the canal. There has been no further stenosis. Conclusion: Pinch skin grafting in medial meatal fibrotizing otitis is a promising technique for restoring the epithelium in this chronic condition. The long-term viability of the epithelium and the affect on disease progression deserves further investigation.

Intermediate cell histiocytosis: a case report of a rare disorder

Histiocytoses are a heterogeneous group of disorders including: X, non-X, as well as the rare intermediate cell histiocytosis. This classification is based on clinicopathological as well as ultrastructural aspects. Intermediate cells belong to the dendritic cell group involved in antigen presentation to lymphocytes. These cells characteristically express S-100 and CD1a and lack Birbeck granules. We report a case of an 80 year old male with intermediate cell histiocytosis. This patient presented with multiple pruritic firm papules and nodules on the bilateral anterior lower extremities. An extensive systemic work-up revealed only a single lytic lesion in the skull. He received high potency topical steroids with good resolution of his pruritus, but with no effect on the cutaneous nodules. He has remained without systemic involvement after one year and the lytic lesion remained unchanged.

An approach to the treatment of anogenital pruritus.

The anogenital area is a common location for pruritic complaints. Specific terms for chronic itch in this location have included pruritus vulvae, pruritus ani, lichen simplex chronicus, and neurodermatitis. A male counterpart to pruritus vulvae, pruritus scroti, is less common. Acute anogenital pruritus is usually caused by infections or contact dermatitis. In chronic pruritus, inflammatory dermatoses and malignancies must be ruled out. In idiopathic anogenital pruritus or neurodermatitis, the skin findings should be limited to lichenification and excoriations. Skin findings may be entirely absent. When treating anogenital pruritus, topic irritants and potential sensitizers must be eliminated. Cleansing and toilet habits must be addressed. A short course of a high-potency topical steroid should bring moderate to complete relief. Sedating antihistamines may limit nighttime symptoms. In some patients, psychotropic agents are required to achieve adequate sedation. Antidepressants may be required in patients refractory to treatment or with underlying psychiatric disorders.

DRUG PRESCRIBING PATTERN IN DERMATOLOGY IN A TEACHING HOSPITAL IN WESTERN NEPAL

The aim was to monitor drug prescribing for patients attending the dermatologyservices (OPD) of Manipal Teaching Hospital (MTH). 292 prescriptions of patientsattending the dermatology OPD of MTH attached to MCOMS, Nepal were collectedby a random once weekly survey between July 2000 to June 2001. This informationwas analysed in consultation with clinical collaborators and critically evaluated usingWHO guidelines. The average number of drugs prescribed was 2.42 drugs/prescription.Only 13%(91 out of 708) of the drugs were prescribed in generic names. The mostcommonly prescribed topical drugs were topical steroids and their combinations (28%)followed by topical antifungal agents (12.5%). The most commonly prescribed systemicagents were antihistamines (47.6%) followed by antimicrobials (20%) and antifungalagents (12%). Frequency of administration and site of application were specified inthe majority of the prescriptions (82%) of topically administered drugs but dose/strength of topical preparations were specified in only 11 prescriptions. The durationwas not specified for 9 of the systemically prescribed drugs and 341 of all the topicaldrugs prescribed. In two patients, 2 medium or 2 high potency topical steroids wereprescribed together with systemic steroid administration. Patients who receivedsystemic antiiungal agents (34) also got a topical one simultaneously. In this study, agreat majority of the drugs were prescribed in brand names (87 %). Drugs should beprescribed in their generic names to * avoid confusion and to minimize the costs. Inthis study, on some occasions, prescriptions may have been written imprecisely/inappropriately.Key Words: Prescribing pattern, Dermatology, Nepal.

The effects of a high-potency topical steroid on cutaneous healing of burns in pigs.

Burns are dynamic injuries that tend to progress over the course of several days. Steroids inhibit the formation of vasoconstrictive prostanoids that may contribute to this progression of injury. The authors hypothesized that adding topical steroids to a standard antimicrobial agent would reduce the progression of burns and accelerate reepithelialization without increasing infection rates. This was a prospective, blinded, controlled, experimental trial. Forty-eight standardized second-degree burns were created by applying an aluminum bar preheated to 80 degrees C to the flanks of isoflurane-anesthetized young pigs for 20 seconds. Three equal sets of 16 burns were randomly treated with silver sulfadiazine cream (SSD), clobetasol propionate 0.05% (CP), or both (SSD+CP). Daily dressing changes were performed for 14 days. Full-thickness biopsies were taken after injury and at one, two, seven, ten, and 14 days for blinded histopathological evaluation using hematoxylin and eosin (H&E) staining. The primary outcome was the % reepithelialization (REP) calculated by dividing the length of the neoepidermis by the section's total length (interobserver correlation = 0.99). Depth of injury was measured for each dermal element (collagen; epithelial, mesenchymal, and vascular cells; and vessel thrombosis). Comparisons across groups were performed using one-way analysis of variance (ANOVA). A repeated-measures ANOVA was used to compare injury depths over time. This study had 80% power to detect a 33-percentage point difference in REP across groups (two-tailed alpha = 0.05). Pretreatment burn depths were similar across groups. While burn depth changed over time, there was no difference between the groups in burn injury progression. There was no difference across the groups in REP or infection rates at all times. Addition of a potent topical steroid to standard antimicrobial topical agents does not reduce burn depth or accelerate reepithelialization after burns.

The Effects of a High‐potency Topical Steroid on Cutaneous Healing of Burns in Pigs

Abstract Objective: Burns are dynamic injuries that tend to progress over the course of several days. Steroids inhibit the formation of vasoconstrictive prostanoids that may contribute to this progression of injury. The authors hypothesized that adding topical steroids to a standard antimicrobial agent would reduce the progression of burns and accelerate reepithelialization without increasing infection rates. Methods: This was a prospective, blinded, controlled, experimental trial. Forty‐eight standardized second‐degree burns were created by applying an aluminum bar preheated to 80°C to the flanks of isoflurane‐anesthetized young pigs for 20 seconds. Three equal sets of 16 burns were randomly treated with silver sulfadiazine cream (SSD), clobetasol propionate 0.05% (CP), or both (SSD+CP). Daily dressing changes were performed for 14 days. Full‐thickness biopsies were taken after injury and at one, two, seven, ten, and 14 days for blinded histopathological evaluation using hematoxylin and eosin (H&amp;E) staining. The primary outcome was the % reepithelialization (REP) calculated by dividing the length of the neoepidermis by the section's total length (interobserver correlation = 0.99). Depth of injury was measured for each dermal element (collagen; epithelial, mesenchymal, and vascular cells; and vessel thrombosis). Comparisons across groups were performed using oneway analysis of variance (ANOVA). A repeated‐measures ANOVA was used to compare injury depths over time. This study had 80% power to detect a 33‐percentage point difference in REP across groups (two‐tailed alpha = 0.05). Results: Pretreatment burn depths were similar across groups. While burn depth changed over time, there was no difference between the groups in burn injury progression. There was no difference across the groups in REP or infection rates at all times. Conclusions: Addition of a potent topical steroid to standard antimicrobial topical agents does not reduce burn depth or accelerate reepithelialization after burns.

Pediatricians who Prescribe Clotrimazole-Betamethasone Diproprionate (Lotrisone) often Utilize it in Inappropriate Settings Regardless of their Knowledge of the Drug's Potency

Clotrimazole-betamethasone diproprionate (C-BMV) is a fluorinated, high potency topical steroid that has been formulated with clotrimazole in the brand-named product, Lotrisone. The product is frequently used inappropriately in intertriginous areas, particularly in children. The following evaluates the use of this combination based upon a survey of 106 US-based pediatricians with at least two years post-residency, who attended the 1999 American Academy of Pediatrics. Of pediatricians who prescribe C-BMV, 23% prescribe it for diaper dermatitis. 11% of C-BMV prescriptions exceed the recommended duration of therapy. Only 18% of prescribing pediatricians correctly identify "Lotrisone" as a high potency steroid. There is no significant association between knowledge of C-BMV potency and frequency of use (p>.1). These self-reported data confirm and complement the findings of previous studies that used representative national data to assess the use of C-BMV. Pediatricians continue to utilize C-BMV in inappropriate settings, such as diaper dermatitis, regardless of their knowledge of the agent's potency. Our advice is to refrain from using high-potency steroids, such as C-BMV, in pediatric cases as there are more appropriate, safer alternatives with many fewer side effects.

New treatments for atopic dermatitis

The pathogenesis of atopic dermatitis (AD) is a complex inflammatory process involving resident and infiltrating cells of the skin, including keratinocytes, Langerhans’ cells; lymphocytes, mast cells, eosinophils; and cytokines, chemokines, and other mediators (see article by Leung elsewhere in this issue). 22 As in other allergic diseases, the inflammatory infiltrate reflects a predominant Th2 cytokine profile, but unlike in other allergic diseases, Th1 cytokines also have a role. Therapies for AD must target this complex inflammatory process. The mainstay of therapy for AD is skin hydration, avoidance of irritants, and use of topical steroids (see article by Boguniewicz and Nicol elsewhere in this issue). Topical steroids are not always effective and can lead to significant topical and systemic side effects. They may cause cutaneous atrophy, striae, bruisability, and telangiectasia of the skin. High-potency topical steroids can lead to systemic absorption and growth suppression in children. Alternative anti-inflammatory agents would be beneficial. This article discusses new topical immunodulators and other novel therapies for AD, including the following: Topical immunomodulators: Topical tacrolimus (FK506, Protopic) Topical pimecrolimus (ASM981, Elidel) Systemic immunomodulators: Mycophenolate mofetil (MMF; CellCEPT) Interferon-gamma (IFN-) Intravenous immunoglobulin (IVIg)