Irritant topical steroids

Hydroquinone is usually more effective when utilized in combination with other agents such as topical retinoids alone or topical retinoids and topical steroids (see Table 14.1). The addition of a weak topical steroid reduces the irritant effect of hydroquinone, but the treat-... 

The first line of treatment is usually the application of topical products, ranging from over-the-counter products to topical steroids. Emollients may be used to reduce dryness and scaling, as well as reducing the hyperproliferation associated with plaque psoriasis. The use of vitamin D analogues, tazarotene, dithranol or coal tar preparations aims to lessen or remove the patient s scaly plaques. However, excess use can irritate the skin and their use is not recommended for the more irritant forms of psoriasis. Tar baths and tar shampoos (containing coal tar) may help with managing the condition. Treatment, if nonirritating, should be continued for 4-6 weeks and thereafter assessed. Emollients... 

Associated toxic epithelial keratitis should respond to blepharitis treatment. Topical steroids are generally not required imless the cornea is significantly involved or a phlyctenule is present. In this case prednisolone 0.12% used two or three times a day for a few days may be used. Combination steroid-antibiotic ointments, such as tobramycin-dexamethasone or the topical combination drop tobramycin-loteprednol, may prove to be useful for those patients complaining of excessive itching and burning. Steroids control the hypersensitivity component that is often present and reduce the congestion and irritation that often provoke the patient to rub the eye and aggravate the blepharitis. 

Pingueculae may become inflamed, resulting in so-called pingueculitis. The most common causes of such inflammation are mechanical irritation or ocular surface disease. Irritation by the edge of a contact lens is a frequent cause (Figure 25-34).Treatment includes elimination of the causal fector, increased lubrication, and a short course of topical steroids when inflammation is significant. 

Allergic cement eczema seems to be more severe than irritant cement eczema (see Chap. 71). Construction workers with allergic cement eczema have more frequent episodes of hand eczema and requirements for topical steroid treatment (Avnstorp 1989a). The persistence of allergic cement eczema is not solely caused by exposure to Cr(VI). It is, in part, also associated with daily irritation of the skin by wet cement. If a worker is advised to change occupation or to be retrained, it is therefore essential that the new job should not involve contact with abrasive wet work processes or contact with other irritants such as, for example, cutting oils. 

In Denmark, very few workers took sick leave due to irritant cement eczema. Among 122 construction workers, only one had taken sick leave due to irritant cement eczema within the past 12 months. In the same period, three had consulted a dermatologist and four had used topical steroid treatment. Twelve workers with irritant cement eczema did not change occupation, became unemployed or took early retirement more often than expected for the whole group of workers (Avnstorp 1989a). 

Dilute topical steroids may be beneficial in reducing irritation and oedema at exposed sites. These, however, have little or no effect on the healing of the lesion. 

Rubefacients act by counter-irritation produced as a result of local vasodilation, resulting in a warm sensation that masks the pain. Counter-irritants should not be applied on broken skin or before or after taking a hot shower. Examples of counter-irritants include salicylates, nicotinates, capsicum, menthol and camphor. Ketoprofen is an example of a non-steroidal anti-inflammatory drug that is available as a topical preparation indicated in painful musculoskeletal conditions. 

In 1948, Edward C. Kendall, who clarified steroid structures during the 1930s (see chapter 4), and Philip S. Hench (1896-1965), at the Mayo Clinic, demonstrated that the steroid hormone cortisone relieves symptoms of rheumatoid arthritis. Kendall, Hench, and Tadeus Reichstein would share the 1950 Nobel Prize in physiology or medicine. Although Lewis Sarett (1917-99) at Merck had accomplished a total synthesis of cortisone in 1944 (Woodward published a more elegant one in 1951), cortisone and its close derivatives would have remained extremely expensive were it not for the efforts of Percy L. Julian (1899-1975). As soon as he learned of the Mayo Clinic discovery, Julian developed a rapid, inexpensive synthesis of Reichstein s Substance S, also isolated ftom the adrenal cortex. This steroid is easily converted to dihydrocortisone and Julian s pathway remains today the major commercial route to this over-the-counter topical remedy for sunburn, mosquito bites, and other uncomfortable skin irritations. 

Patient s responsibilities include Application of inadequate topical products (scrubs, exfoliating agents) before complete reepithelization This results in severe irritation with intense erythema and edema. Prescribe topical and systemic steroids for a few days. Prescribe bleaching agents (hydroquinone 3-4%, kojic acid, arbutin, azelaic) acid after reepithelization as the risk of hyperpigmentation is increased. 

Important Treatment Modalities. Common ways of dealing with dermatological problems are topical treatments (such as ointments and creams) and oral treatments (drugs taken by mouth). Any bodily injury, irritation, or trauma that eliminates water, lipids, or protein from the epidermis compromises its function. Restoration of the normal epidermal barrier can often be accomplished using mild soaps and emollient creams or lotions. The often-cited dermatologic adage is If it is dry, wet it if it is wet, dry it. Consequently, wet compresses are a frequendy used remedy. A multitude of other topical treatments are available, from antibiotic, antiviral, or steroid ointments applied to treat infectious diseases or eczema to vitamin D derivative creams for psoriasis and retinoid creams for acne. Drugs can also be taken orally to treat a variety of conditions such as acne and autoimmune disorders. 

O Lippmann. Local irritating effect caused by topical use of steroids in the eye. AMA Arch Ophthalmol 57 339-344, 1957. 

The therapeutic value of locally applied retinoic acid in psoriasis is disputed. It appears that relatively high concentrations are necessary to obtain a satisfactory therapeutic effect. Irritation from these high concentrations remains a troublesome side effect. Kaidbey et al. (88 ), in a study of the effect of topically applied retinoic acid with steroid ointment, described a patient who inadvertently transferred the 0.3% retinoic... 

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