TOPICAL CORTICOSTEROIDS IN PEDIATRIC AGE GROUP
Dr. Yashwanth Tawade *
Pune*
Topical corticosteroids are important in treatment of dermatologic disease. However it is also a double edged weapon and therefore should used carefully especially in children. Today various topical steroid preparations are available. To choose a proper preparation one must have the thorough knowledge of topical steroids in all its aspects. The efficacy and side effects of topical corticosteroids depends upon the structure of molecule, the vehicle and the skin onto which it is applied.
Mechanism of Action of TCS 1
Topically applied corticosteroids (TCS) penetrate the cell membrane and combine with receptors. Receptor-corticosteroid complexes interact with DNA in the nucleus and cause release of modified RNA. This modified RNA cause release of programmed proteins which has got enzymatic and hormone properties and is responsible for immunosuppressive and anti-inflammatory effect.

One of the proteins is cortin which blocks release of arachidonic acid from phospholipids present in the cell membrane.
Effective Action of TCS 2
  1. Anti-inflammatory
  2. Immunosuppressive
  3. Inhibits DNA synthesis
  4. Vasoconstriction
Indications in Pediatric Age Group
  1. Eczema - endogenous (atopic) or exogenous (contact)
  2. Psoriasis
  3. Vitiligo
  4. Lichen planus
  5. Morphea
  6. Granuloma annulare
  7. Alopecia areata
  8. Discoid lupus erythematosus
  9. Patch stage lymphoma
Selection of TCS
TCS are to be used with caution in children. The general principle is to use steroids as mild as possible for as short period over as small area as possible.

Infants are at increased risk of side effects because of higher ratio of skin surface area to body weight and due to increased absorption of the drug into the system. It also remains in the body for longer time due to slow metabolism.

Effectiveness as well as side-effects of the particular preparation depends upon its:
  1. Potency
  2. Vehicle
  3. Frequency of use
  4. Amount used
  5. Duration of application
  6. Method of application
  7. Area of application
  8. Area to be treated
  9. Disease to be treated
Potency of a molecule(3)
A majority of marketed TCS preparations have not been tested in children. Guidelines for their use in pediatric patients have been largely derived from adult studies.

Potency

Drug

Low

Hydrocortisone 1%
Desonide 0.05%

Medium

Clobetasone butyrate 0.05%3
Fluticasone propionate
Hydrocortisone butyrate 0.01%
Mometasone furoate 0.01%

High

Fluocinolone acetonide 0.025%
Betamethasone dipropionate 0.05%
Betamethasone 17 valerate
Clobetasol propionate 0.1%



  • Only low potency should be used for chronic conditions
  • Medium potency preparations can be used for acute flare up of moderate inflammatory dermatoses
  • High potency are used in severe inflammatory dermatoses eg, psoriasis and only for short duration

Vehicle
The vehicle in which the steroid molecule is incorporated is very important.

A. Ointment (greasy) - W/O - water in intermittent phase and oil in continuous phase:
  • These preparations are useful for dry dermatoses
  • The ointment base has occlusive effect
  • However it is messy
  • For extensive area greasy base ointment has to be diluted in greasy base diluent like petrolatum or emulsifying agent and not in cream base like nivea
  • Ointment base are used usually for extremities and should not be used in hairy area

B. Creams: O/W - oil in intermittent phase and water in continuous phase:
  • They are less hydrating
  • Usually used for acute dermatoses characterized by oozing and crusting
  • It is cosmetically more acceptable even though it is less effective
  • For extensive areas it can be diluted in a cream base

C. Lotions:
  • The lotions are recommended for hairy areas
  • Lotions can be alcohol base or lubricant base
  • In patients with acute exudative dermatoses lotions with alcohol base are preferred and in with chronic dry dermatoses of scalp lubricating base are preferable.

D. Gel:
  • Gels are transparent semisolid preparations that liquefy on contact with warm skin drying as a greaseless non-occlusive film.
  • Gels are suitable for scalp

E. Emollient cream:
  • They have combined features of both creams and ointments.
  • They are accepted cosmetically since they tend to hydrate the skin and are not as greasy as conventional ointment bases.

3. Frequency and Duration of Application⁵:
Even though there are no clear-cut guidelines normally TCS are applied twice daily. However, once daily application is sufficient for clinical response.
The therapy duration of 7 to 14 days is usually sufficient.
In chronic cases, topical pulse therapy i.e., application of medicine only on two consecutive days a week helps to reduce side effects. (Saturday-Sunday therapy).

4. Dose of TCS⁶ :
It is advisable to go by finger tip unit (FTU). An FTU is the amount of ointment expressed from the tube with 5 mm nozzle applied from the distal skin crease to the tip of the palmer aspect of index finger. One FTU can be applied to one palm size in severe cases and palm sizes in mind cases.

5. Location of Dermatoses:
Lesions on the palms and soles require more potent agents. Lesions on eyelids and scrotum require very mild agents. The depth of the lesion is also important lesions on epidermis are more sensitive than lesions in dermis.

6. Disease to be Treated⁷:
The resident sensitive dermatoses like plaque type psoriasis, lichen planus, lichen simplex chronicus require high potency steroids and sensitive dermatoses like atopic dermatitis, seborrheic dermatitis and intertrigo require low potency steroids.

7. Combinations⁸:
  • There are various combinations available in the market.
  • The antibiotic - steroid combination is required for infected eczema in the initial period.
  • The anti-fungal - steroid combination is needed in perianal and intertriginous area.
  • The combination with neomycin should not be used.
  • The combination of TCS with salicylic acid is useful in palmoplantar thick lesions like psoriasis.
Local side-effects of TCS(9)
  1. Atrophic changes
    1. Steroid atrophy
    2. Telangiectasia
    3. Striae
    4. Purpura
  2. Infections
    1. Masked microbial infections
    2. Granuloma gluteale formation
  3. Ocular changes
    1. Glaucoma
    2. Cataract
  4. Pharmacological Effects
    1. Steroid rebound phenomenon
    2. Rosacea
    3. Perioral dermatitis
    4. Hypertrichosis
    5. Hyperpigmentation
    6. Hypopigmentation
Systemic side-effects of TCS
The systemic side effects can be seen after using potent steroids for prolonged period.
  1. HPA suppression - This is seen after use of more than 50 gm/week of highly potent steroid.
  2. Undue fatigue is also seen after prolonged use of potent steroid probably due to electrolyte imbalance.

Guidelines for Use of TCS in Children
  1. Initially use appropriate potent compound to achieve disease control.
  2. To continue with less potent preparation after sufficient response.
  3. To reduce the frequency of application.
  4. To continue daily application with weak preparation.
  5. To taper the application upon complete healing.

References :
  1. Warner MM, Camisa C. Topical corticosteroids. In:Wolverton SE editor Comprehensive dermatologic drug therapy : WB Saunders Company, Philadelphia, Pennsylvania 2001.
  2. Krofchik BR. The use of topical steroids in children. Semin Dermatology 1995;14:70-4.
  3. hepburn d, Yohn JJ, Weston WL. Topical steroid treatment in infants, children and adolescents. In: Collen IP, Dahl MV, Golitz le, Greenway children and adolescents. In: Collen IP, Dahl MV, Golitz le, Greenway HT, Schachner LA, eds. Advances in Dermatology, St. Louis: Mosby-Year book 1994.
  4. Cornell RC, Stoughton RB. What determine Clinical Effectiveness. In: Topical Corticosteroids. Guidelines for therapy. Series II Dermatology, Hoeshst Marian roussel, 1985;22-23.
  5. West DP, Micali G. Principles of Pediatric Dermatological Therapy. 27.1:1736-7.
  6. Long LC, Finlay AY. The fingertip unit - a new practical measure. Clin Exp Dermatol 1991;16:444-7.
  7. Cornell RC, Stoughton RB. How to match the steroid to the dermatoses. In: Topical Corticosteroids - Guidelines for therapy. Series II Dermatology, Soeshst marian roussel, 1985;26-7.
  8. Criton S. Topical Corticosteroids. In: perspectives in clinical.
  9. Hengge UR, ruzicka T, Schwart Ra et al. Adverse effects of topical glucocorticoids JAAD, Selected articles from vol.54, issues 1 (Jan 2006) & 2 (Feb 2006);1-15.
How to Cite URL :
Tawade Y D.. Available From : http://www.pediatriconcall.com/fordoctor/ Conference_abstracts/report.aspx?reportid=214
Disclaimer: The information given by www.pediatriconcall.com is provided by medical and paramedical & Health providers voluntarily for display & is meant only for informational purpose. The site does not guarantee the accuracy or authenticity of the information. Use of any information is solely at the user's own risk. The appearance of advertisement or product information in the various section in the website does not constitute an endorsement or approval by Pediatric Oncall of the quality or value of the said product or of claims made by its manufacturer.
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.