Local corticosteroids

Concomitant weekly PA is given with triam-cynolone acetonide (TA) - - dexamethasone (DxM) -I- lignocain (LNC) in ratio s of 60-20-20% until the mean local VAS is < 10 mm (scale 0-100 mm). The rationale of this mixture is instant anesthesia for up to 4 hours by LNC, efficacy of DxM commencing after 4 hours and lasting for 4 days and effects of TA which start after 4 days and last for <6 days. Efficacy of PA lasts at least for 10-14 days unless the joint becomes refractory to local corticosteroids. Weekly PA is effective in RA (see Darmawan et al., 2003) and AS (see Darmawan et al., 2006) and is equally effective in musculoskeletal manifestations of LN (see Darmawan et al., 1999). 

Fokkens WJ, Godthelp T, Holm AF, Klein JA Local corticosteroid treatment The effect on cells and cytokines in nasal allergic inflammation. Am J Rhinol 1998 12 21-26. 

Nerve compression can be relieved by local corticosteroid (prednisolone) or nerve block (local anaesthetic) nerve destruction can be achieved by alcohol, phenol. 

Skin biopsies in the last two patients showed microthrombi of the dermal capillaries and a necrotic epidermis. Immunofluorescence showed only fibrinogen. Some bullous lesions were still present 1 month after withdrawal in the first patient, while the second patient responded to local corticosteroids and a reduced dose of pegylated interferon alfa, but continued to have episodes of severe pruritus. 

Topical aciclovir is not well tolerated by patients after a deep peel because of the burning sensation it triggers. If pain is very local, EMLA cream can be used cautiously, as it is absorbed more readily through skin that has no stratum corneum and is damaged by herpes. Local corticosteroids should not be used. 

Local adverse effects from ICSs include oropharyngeal candidiasis and dysphonia that are dose-dependent. The dysphonia appears to be due to a local corticosteroid-induced myopathy of the vocal cords. The use of a spacer device can decrease oropharyngeal deposition and thus decrease the incidence and severity of local side effects. In infants who require delivery through a facemask, the parent should clean the nasal-perioral area with a damp cloth following each treatment to prevent topical candidal infections. 

The implant, which consisted of a 5-mg drug core surrounded by ethylene vinyl acetate and polyvinyl alcohol, was inserted through the pars plana after pars plana vitrectomy and lensectomy. The device was well tolerated and the patient s eye remained quiet and did not require any supplemental local corticosteroids. The visual acuity remained at 20/400 in the left eye and the intraocular pressure remained normal. In contrast, the patient had two episodes of recurrent anterior segment inflammation in the right eye, despite intensive topical steroids. After 10 months, the intraocular inflammation recurred in the patient s left eye, presumably because the device and surrounding tissues had become depleted of dexamethasone. 

Nancey S, Freymond N, Catelain A, et al. Effects of local corticosteroids on acute experimental urticaria. Eur J Dermatol. 2004 14 323-6. 

Ko H-J, Kim Y-R, Park K-S, Cho C-S, Kim H-Y. Clinical Images Kienbock disease resulting from local corticosteroid injections. Arthritis Rheum 2009 60(6) 1596. 

The conservative treatment of carpal tunnel syndrome indudes wrist splints during sleep, nonsteroidal anti-inflammatory drugs and local corticosteroid injections adjacent to the tunnd. If such treatment fails or progressive sensory loss and muscle weak-... 

D Agostino MA, Ayral X, Baron G et al (2005) Impact of ultrasound imaging on local corticosteroid injections of symptomatic ankle, hind-, and mid-foot in chronic inflammatory diseases. Arthritis Rheum 53 284-292 Delfaut EM, Demondion X, Bieranski A et al (2003) Imaging of foot and ankle nerve entrapment syndromes from well-demonstrated to unfamiliar sites. RadioGraphics 23 613-623... 

NOTES TO MEDICAL DOCTOR Hydrogen peroxide at these concentrations is a strong oxidant. Direct contact with the eye is likely to cause corneal damage especially if not washed immediately. Careful ophthalmologic evaluation is recommended and the possibility of local corticosteroid therapy should be considered. 

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