Corticosteroids are double edged medications in psoriasis. Topical steroids can control the disease activity fast, but cause a number of side effects. Corticosteroids are the most frequently prescribed treatment for mild to moderate psoriasis because they decrease the rate at which skin cells grow and reduce inflammation. Steroids also relieve the itch that often accompanies psoriasis.
Classes of Topical Corticosteroids
Topical steroids are classified according to their strength. They vary from very strong, super potent (Class 1), to very weak or least potent (Class 7). The super potent steroids are very effective in controlling severe inflammation of the skin, but also have high incidence of side effects. As the potency decreases, so does the effectiveness and side effects.
Topical corticosteroids come in several forms, including creams, lotions and ointments. Creams and solutions are a strength below in classification than ointments.
Side Effects of Topical Corticosteroids
Topical steroids have both topical and systemic side effects.
Topical Side Effects of Topical Steroids
- Topical application of steroids causes thinning of the skin by causing atrophy of the skin layers.
- Dilation of capillaries that are shown through the thinned skin, known as telengiectasia.
- Stretching and splitting of the skin causing stretch marks or striae dystensiae.
- Pimple like eruptions on the treated area, especially on the face, chest, back and limbs, called steroid acne.
- The main problem with topical (and systemic steroids) is the rebound phenomenon or exacerbation of the lesions that occur if the steroids are suddenly stopped or withdrawn. A localized form of psoriasis can become generalized or a generalized form can get precipitated as pustular or erythrodermic forms when steroids are withdrawn.
- Higher strength steroids should be avoided on the face, especially near eyes, on the body folds and near the genital organs. Steroids used near eyes for prolonged duration have been shown to cause cataract formation in the eyes and glaucoma.
- Steroids are best avoided in the presence of infection as these can exacerbate infections.
- Other topical side effects of topical steroids include easy bruising, purpura, skin ulceration, non healing of ulcers, exacerbation of infections, perioral dermatitis, rosacea, hypo pigmentation, hyper pigmentation, and excessive hair growth. Mistaken application of steroids on ring worms cause changes in morphology and spread of the fungal infection, known as tinea incognito.
Systemic Side Effects of Topical Steroids
- Adrenal Suppression. Because of the absorption of potent steroids into the blood stream, the adrenal glands could become suppressed and their production of normal steroids will suffer as a result. This can have far reaching effects on the body. If prolonged, this can produce a cushingoid (moon like) face in patients and cause other systemic effects.
- Tachyphylaxis.The body develops resistance to the topical application after some time.
How to Avoid the Side Effects of Topical Steroids in Psoriasis
- Combination and Sequential Therapies.Corticosteroids are alternated or combined with other anti- psoriatics like calcipotriene and tazarotene so as to reduce the cumulative effects as well as the tachyphylaxis. This is known as topical sequential therapy in psoriasis.
- Use of graded strengths of corticosteroids will help in avoiding the topical side effects like atrophy (thinning) and stretch marks.
- Gradual withdrawal and replacement with other safer applications.
- If superpotent or potent steroids are used for long durations, changing to a moderate strength topical steroid for one week after every two weeks of application, will help reduce the side effects of the potent steroids.
- Potent and superpotent topical steroids should preferably have an application free interval of about 5-7 days after every 2 weeks of application. This will help in reducing the side effects.
- Never use higher strength topical steroids in infants, except under the supervision of a dermatologist.
- Avoid moderate to superpotent classes of topical steroids in sensitive areas like face and body folds.
- If prolonged use of topical steroids is indicated, steroid sparing topical applications like calcineurin inhibitors tacrolimus or pimecrolimus should be used once the acute stage is under control.
Finally, the higher potency topical steroids should only be used under the supervision of a dermatologist or physician trained in the use of steroids in skin diseases. Before prescribing or using any topical corticosteroids in psoriasis or in any other skin diseases, it is advisable to learn the basics about the classes of topical corticosteroids.
References
- Hengge UR, Ruzicka T, Schwartz R et al. Adverse effects of topical glucocorticosteroids. J Am Acad Dermatol. 2006; 54:1-15
- Topical Therapy, in Rook’s Textbook of Dermatology, 7th Edition, 2004
Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or suite101 will not be responsible for any consequences. The images provided are for illustration purpose only.
Hanish Babu - Dr.Hanish Babu, MD is a dermatologist and a feature writer on Suite101.com with more than 200 articles related to skin diseases on the ...
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