Corticosteroids psoriasis

Corticosteroids have a range of activity. They have potent antiinflammatory and immunosuppressive activity. Many synthetic drugs are available as corticosteroids. In appropriate doses, these are used as replacement therapy in adrenal insufficiency. The topical application of corticosteroids is safer when compared with systemic use. Corticosteroids should be used in smaller doses for the shortest duration of time. A high dose may be used for life-threatening syndromes or diseases. A tapering pattern of withdrawal should be followed to avoid complications of sudden withdrawal. Systemic therapy is indicated in a variety of conditions. These are administered by intraarticular injections with aseptic conditions for rheumatoid arthritis and osteoarthritis. In skin diseases, such as eczema, contact dermatitis, and psoriasis, corticosteroids are used topically. In some cases, steroids are combined with antimicrobial substances such as neomycin. 

The topical and oral use of retinoids for treatment of hyperkeratotic disorders such as psoriasis and Darier s disease has long been established. Systemic retinoid therapy is often combined with topical diugs such as corticosteroids, dithranol, tar, and also UVA/UVB phototherapies where synergistic effects have been reported. 

Topical corticosteroids exert localized anti-inflamma-toiy activity. When applied to inflamed skin, they reduce itching, redness, and swelling. These drugs are useful in treating skin disorders, such as psoriasis, dermatitis, rashes, eczema, insect bite reactions, and first-and second-degree burns, including sunburns. 

Topical therapy is the initial drug treatment strategy for patients with mild to moderate psoriasis. It is estimated that approximately 70% to 80% of all patients with psoriasis can he treated adequately with use of topical therapy.1 Topical therapies include corticosteroids, coal tar products, anthralin, vitamin D3 analogues such as calcipotriol, retinoids such as tazarotene, and topical immunomodulators such as tacrolimus and pime-crolimus.18 Vitamin D3 analogues and topical retinoids all affect keratinocyte functions and the immune response. Currently, these are in wider use than is either anthralin or coal tar preparations. 

Vitamin D analogues (calcipotriol, calcitriol, and tacalcitol) are also frequently selected as initial pharmacotherapy in the management of mild to moderate psoriasis.2 These inhibit keratinocyte differentiation and proliferation and maybe antiinflammatory.2 Unlike corticosteroids, tachyphylaxis does not occur with prolonged use. Clearance of lesions should occur after 4 to 6 weeks of treatment.2 Lack of response by 8 weeks... 

Keratolytic agents such as salicylic acid are often added to bath oil or shampoos (typically 3% to 4%) for scalp psoriasis.10 Salicylic acid can also be added to topical corticosteroid preparations to enhance steroid penetration (salicylic acid breaks down keratin). 

Hydroxyurea is an older agent still used occasionally today for patients with psoriasis however, there have been recent precautions about its use in the elderly and cutaneous vasculitic toxicities in patients with myeloproliferative disorders.29 Toxicity associated with tacrolimus has limited its use in psoriasis. Azathioprine has a slow onset and significant toxicity.29 Oral corticosteroids are reserved for severe or life-threatening conditions such as severe psoriatic arthritis or exfoliative psoriasis prolonged oral steroid use should be avoided.10... 

Ointments are the most effective formulations for psoriasis because they have an occlusive oily phase that conveys a hydrating effect and enhances penetration of the corticosteroid into the dermis. They are not suited for use in the axilla, groin, or other intertriginous areas where maceration and folliculitis may develop secondary to the occlusive effect. 

Tazarotene (Tazorac) is a synthetic retinoid that is hydrolyzed to its active metabolite, tazarotenic acid, which modulates keratinocyte proliferation and differentiation. It is available as a 0.05% or 0.1% gel and cream and is applied once daily (usually in the evening) for mild to moderate plaque psoriasis. Adverse effects are dose- and frequency related and include mild to moderate pruritus, burning, stinging, and erythema. Application of the gel to eczematous skin or to more than 20% of body surface area is not recommended because this may lead to extensive systemic absorption. Tazarotene is often used with topical corticosteroids to decrease local adverse effects and increase efficacy. 

Topical corticosteroids may be used for short-term treatment of acute flare-ups (see Table 16-1 in Chap. 16 on Psoriasis). Most corticosteroids are applied once or twice daily. High-potency agents are used for less than 3 weeks for flare-ups or for lichenified (thickened) lesions. Moderate-potency steroids may be used for more chronic conditions, and low-... 

Eczema is managed by emollients and topical corticosteroids. Fatty cream base is an emollient and is therefore indicated in eczema. Podophyllum is used in warts, lidocaine is an anaesthetic, calcipotriol is used in psoriasis and... 

Psoriasis Do not use topical corticosteroids as sole therapy in widespread plaque psoriasis. 

Uses Psoriasis Action Keratolytic Dose Apply daily Caution [C, ] Contra Acutely inflamed psoriatic eruptions, erythroderma Disp Cream SE Irritation hair/fingemails/skin discoloration Interactions T Tox if used immediately after long-term topical corticosteroid therapy EMS None OD Unlikely... 

Numerous glucocorticosteroids for topical application are available. Essentially they all suppress the symptoms of inflammatory and hypersensitivity reactions and their mechanism of action is similar. Their indications include seborrhoeic and atopic dermatitis, phototoxic reactions, psoriasis, chronic discoid lupus, hypertrophic lichen planus and alopecia areata. However it has to be kept in mind that the use of corticosteroids for these conditions in most cases only gives symptomatic relieve and that the problem tends to recur on cessation of therapy. Traditionally topical corticosteroid formulations are grouped according to approximate relative efficacy. This efficacy is determined by both the potency of the agent and the concentration in which the corticosteroid is used. 

Topical corticosteroids are most useful in inflammatory dermatoses, such as eczematous dermatitis and psoriasis they may also be helpful in other skin diseases that have a prominent inflammatory component, such as autoimmune blistering diseases (e.g., bullous pemphigoid and pemphigus vulgaris) and lupus erythematosus. 

It is indicated in lymphoblastic leukemia and choriocarcinoma, psoriasis, adjuvant therapy of non-metastatic osteosarcoma and to reduce corticosteroid requirement in patients with severe steroid dependent asthma. 

The remarkable efficacy of topical corticosteroids in the treatment of inflammatory dermatoses was noted soon after the introduction of hydrocortisone in 1952. Numerous analogs are now available that offer extensive choices of potencies, concentrations, and vehicles. The therapeutic effectiveness of topical corticosteroids is based primarily on their antiinflammatory activity. Definitive explanations of the effects of corticosteroids on endogenous mediators of inflammation await further experimental clarification. The antimitotic effects of corticosteroids on human epidermis may account for an additional mechanism of action in psoriasis and other dermatologic diseases associated with increased cell turnover. The general pharmacology of these endocrine agents is discussed in Chapter 39. 

Tar preparations are used mainly in the treatment of psoriasis, dermatitis, and lichen simplex chronicus. The phenolic constituents endow these compounds with antipruritic properties, making them particularly valuable in the treatment of chronic lichenified dermatitis. Acute dermatitis with vesiculation and oozing may be irritated by even weak tar preparations, which should be avoided. However, in the subacute and chronic stages of dermatitis and psoriasis, these preparations are quite useful and offer an alternative to the use of topical corticosteroids. 

Initial therapy consisting of twice daily applications of a medium strength topical corticosteroid combined with once daily topical calcipotriene should provide adequate control for this patient s localized psoriasis. A coal tar shampoo should be initiated for her scalp psoriasis with nightly application of a corticosteroid solution to recalcitrant plaques. 

Tanghetti, E.A., An observation study evaluating the treatment of plaque psoriasis with tazarotene gels, alone and with an emollient and/or corticosteroid. Cutis, 2000, 66 (Suppl. 6) 4—11. 

These include atypical or subtle manifestations of dermatologic conditions such as seborrheic dermatitis, rosacea, psoriasis, atopic dermatitis, and ichthyosis. Classic manifestations of such diseases are diagnosed with relative ease. However, diagnostic difficulty arises in the presence of atypical morphology, lesions masked by topical therapy (e.g., corticosteroids), or exacerbations due to other topical agents (e.g., skin care products).2,10... 

Topical corticosteroids are usually given in combination with other topical treatments for the treatment of chronic plaque psoriasis. Sensitive areas, such as the face, should be treated with a mild corticosteroid and other areas, such as the scalp, with moderate to potent corticosteroids. In general, use should be maintained as early improvements in the condition are not maintained if use is halted. Such a pattern of use may worsen the condition, possibly causing a deterioration of the condition to unstable forms, such as erythrodermic or pustular psoriasis. Co-administration of topical medicaments usually involves alternating administration of each product. Scalp psoriasis is normally treated with softening emollients in combination with salicylic acid with coal tar or sulphur. 

Mr GM took NSAIDs to alleviate the pain and irritation associated with his psoriasis. NSAIDs, such as ibuprofen and indometacin, have been shown to exacerbate psoriasis. Mr GM should be appropriately counselled in his use of pain medication. Further, the patient has failed to give treatment enough time to work in the past, citing associated pain and irritation of his condition. This may be due to the patient s use of ibuprofen, but also to the premature cessation of treatment. The patient should be counselled with regard to the duration of the treatments, and to the possible exacerbation of his condition should he cease treatment too soon. The provision of systemic drugs should be given with caution as, for example, premature cessation of systemic corticosteroid therapy will result in rebound deterioration of the condition. 

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