Topical Steroid Preparations

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. 

Topical preparations usually contain relatively insoluble steroids, such as clobetasol propionate, triamcinolone acetonide, or triamcinolone diacetate. Side effects of this mode of drug application are usually milder and more transient than those seen after systemically administered steroids. However, potent topical corticosteroids, such as clobetasol propionate (Temovate), can suppress adrenal function when used in large amounts for a long time, especially when the skin surface is denuded or when occlusive dressings are employed. Since the high potency topical preparations carry a higher risk of local side effects, their use should be held in reserve. 

Local therapy, such as topical preparations for skin disease, ophthalmic forms for eye disease, intra-articular injections for joint disease, inhaled steroids for asthma, and hydrocortisone enemas for ulcerative colitis, provides a means of delivering large amounts of steroid to the diseased tissue with reduced systemic effects. 

Topical preparations Vehicles for presenting drugs to the skin Emollients, barrier preparations and dusting powders Topical analgesics Antipruritics Adrenocortical steroids Sunscreens... 

Vasoconstriction evidenced by skin blanching correlates with steroid potency in topical preparations. 

BUTCHERS BROOM The roots of Ruscus dculentus contain a mixture of steroid sapogenins called ruscogenins which are structurally similar to diosgenin. These have been formulated into topical preparations for varicose veins and haemorrhoids. 

Neomycin currently is available in many brands of creams, ointments, and other products alone and in combination with polymyxin, bacitracin, other antibiotics and a variety of corticosteroids. There is no evidence that these topical preparations shorten the time required for healing of wounds or that those containing a steroid are more effective. 

Many topical suspensions Knd application in dermatology. Thus, the treatment of acne through topical application of benzoyl peroxide has been particularly. successful the same can be said about local treatment of viral or fungi infection. Other drugs, while having local effect, can spread from the place of application, showing also a systemic action. This is the case, for instance, of steroidal antiinllammaloiy preparations. 

Removal of scales and crust This results in exudative erosions (Fig. 23.3). In exudative phase, apply 3% boric acid solution. Then prescribe a moisturizer to be applied every 3 h and a topical preparation containing an antibiotic in association with a steroid. Explain the necessity of complete avoidance of sun exposure. 

Oral prednisone (20 mg) daily for 1-2 days is helpful to minimize the inflammatory phase of the peels this can be also combined with a topical preparation mixed by patient (prescription class II steroid cream or ointment plus topical antibiotics, like 0.1% gentamycin) that is applied 4-5 times daily for 1-3 days. 

There are hundreds of topical steroid preparations that are available for the treatment of skin diseases. In addition to their aforementioned antiinflammatory effects, topical steroids also exert their effects by vasoconstriction of the capillaries in the superficial dermis and by reduction of cellular mitosis and cell proliferation especially in the basal cell layer of the skin. In addition to the aforementioned systemic side effects, topical steroids can have adverse local effects. Chronic treatment with topical corticosteroids may increase the risk of bacterial and fungal infections. A combination steroid and antibacterial agent can be used to combat this problem. Additional local side effects that can be caused by extended use of topical steroids are epidermal atrophy, acne, glaucoma and cataracts (thus the weakest concentrations should be used in and around the eyes), pigmentation problems, hypertrichosis, allergic contact dermatitis, perioral dermatitis, and granuloma gluteale infantum (251). 

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). 

Erythema, inflammation, pain, and itching caused by contact dermatitis can be effectively treated with topically applied corticosteroids. With such a wide range of products and potencies available, an appropriate steroid selection is based on severity and location of the lesions. Table 62-6 shows a list of topical steroids and their potencies. Higher-potency preparations are used in areas where penetration is poor, such as on the elbows and knees. Lower-potency products should be reserved for areas of higher penetration, such as on the face, axillae, and groin. Low-potency steroids are also recommended for the treatment of infants and children.32,33... 

Because of the increased permeability of their skin, infants are at risk for excessive absorption and toxicity from the use of topical steroids. Although these agents are effective in decreasing inflammation and relieving pruritus, steroid use in infants for the treatment of diaper dermatitis should be limited to only the low-potency preparations.38... 

Soiutions and suspensions - Most topical ocular preparations are commercially available as solutions or suspensions that are applied directly to the eye from the bottle, which serves as the eye dropper. Avoid touching the dropper tip to the eye because this can lead to contamination of the medication and also may cause ocular injury. Resuspend suspensions (notably, many ocular steroids) by shaking to provide an accurate dosage of drug. 

Glucocorticoids are available in a wide range of preparations, so that they can be administered parenterally, orally, topically, or by inhalation. Obviously the oral route is preferred for prolonged therapy. However, parenteral administration is required in certain circumstances. Intramuscular injection of a water-soluble ester (phosphate or succinate) formed by esterification of the C21 steroid alcohol produces peak plasma steroid levels within 1 hour. Such preparations are useful in emergencies. By contrast, acetate and tertiary butylacetate esters must be injected locally as suspensions and are slowly absorbed from the injection site, which prolongs their effectiveness to approximately 8 hours. 

V. Steroid preparations (used topically as antiinflammatory agents)... 

Research teams at Glaxo then undertook the synthesis of derivatives of betamethasone that might afford superior local anti-inflammatory and anti-allergic effectiveness. Using McKenzie and Stoughton s [21] new human-based pharmacologic test that could identify with ease the relative topical potency of steroid inflammatory compounds, a series of 17-esters of betamethasone prepared by Elks [22] was evaluated. This resulted in compounds with new standards of topical potency such as triamcinolone acetonide and fluocinolone acetonide. It was then discovered, that potency peaked with betamethasone-17-valerate and betamethasone-17,21-dipropionate, which were between four- and ten-fold more potent than the standard. 

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... 

Systemic steroids are also the cause of numerous negligence claims.These drugs have side effects that can result in serious injury, even death, and consequently must be used conservatively. Systemically administered drugs, with their risk of systemic complications, should not be used if a topical route of administration suffices, and practitioners must be prepared to justify the selection of a systemic route of administration when complications result and a topical route of administration initially was not used. Whenever systemic steroids are prescribed, practitioners must warn patients of side effects, monitor patients adequately so that preventable injuries can be detected, and document the care rendered. 

The most common form of neomycin administration is topical. The dmg is available in combination with other antibiotics and steroids in numerous ophthalmic, otic, and dermatologic preparations designed to treat a rariety of skin and mucous membrane infections (seeTables 11-6 and 11-7). Topical ocular application of neomycin can result in... 

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