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CME ARTICLE
Year : 2014  |  Volume : 15  |  Issue : 1  |  Page : 1-4

Use and abuse of topical corticosteroids in children


1 Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India
2 Department of Pharmacology, KPC Medical College and Hospital, Kolkata, West Bengal, India

Date of Web Publication2-May-2014

Correspondence Address:
Arijit Coondoo
Block B, Flat #1H, "Canvas", 46/2 Bosepukur Road, Kolkata - 700 042, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.131826

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  Abstract 

Topical corticosteroids (TC) have been in use for more than half a century and are useful for the treatment of various inflammatory disorders in all age groups including children. Children, however, form a special age group because their skin, being more thin and tender, is more susceptible to the side-effects of the drug. Hence dermatologists must be aware of this special situation where TC must be prescribed with utmost caution. Counselling of parents and others handling the children is also imperative for judicious use of the drug. Planned withdrawal of the drug as early as possible helps in avoiding tachyphylaxis and most of the side-effects of the drug.

Keywords: Children, corticosteroids, topical


How to cite this article:
Coondoo A, Chattopadhyay C. Use and abuse of topical corticosteroids in children. Indian J Paediatr Dermatol 2014;15:1-4

How to cite this URL:
Coondoo A, Chattopadhyay C. Use and abuse of topical corticosteroids in children. Indian J Paediatr Dermatol [serial online] 2014 [cited 2019 Dec 11];15:1-4. Available from: http://www.ijpd.in/text.asp?2014/15/1/1/131826


  Introduction Top


Topical corticosteroids (TC) are some of the most commonly used drugs in dermatological practice. They play a vital role in the dermatologists' armory for the treatment of a large number of inflammatory disorders. However, they can cause enough mischief if misused and hence they need judicious handling by both the prescriber as well as the patient. The merits and demerits of topical steroids as a double-edged sword in children, who form a very special category of patients, are discussed in the following paragraphs.


  Topical corticosteroids Top


Sulzberger and Witten in 1952 published the first report of the utility of TC in dermatology. [1] Subsequently a large variety of the molecule in various potencies have been introduced. Topical steroids have been grouped into seven classes in order of decreasing potency. Although superpotent and potent steroids include molecules such as halobetasol and clobetasol (Class I) and betamethasone dipropionate and desoximatasone (Class II), midpotent TCs belong to Class III (triamcinolone), Class IV (mometasone) and Class V (hydrocortisone butyrate). Steroids of low potency are more suitable for the pediatric age group and include desonide, clobetasone and fluocinolone acetonide (Class VI) and hydrocortisone (Class VII). [Table 1] lists the TC approved by Food and Drug Administration (FDA) for children.
Table 1: Topical corticosteroids approved by food and drug administration in children

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Potency of TC is principally measured by the method of vasoconstriction assay. Other assays of glucocorticoid potency are done by experimentally inducing inflammation to suppress erythema and edema and the psoriasis bioassay, which is done to quantify the effect of the TC on psoriatic lesion. [2]

Weaker (low potent) topical steroids are suitable for use in areas where the skin is thin and sensitive such as the face, eyelids, armpits and diaper area including the groins, buttocks and perianal skin. Moderately potent steroids are used for various dermatitis such as atopic dermatitis and allergic contact dermatitis as well as in other disorders such as vitiligo, polymorphous light eruptions and discoid lupus erythematosus. Steroids of higher potency are used in diseases such as psoriasis, lichen planus hypertrophicus, lichen simplex chronicus and lichen amyloidosus where the skin is thickened and penetrability is decreased. [3]

The effects and side-effects of TCs depend mainly on the thickness of skin, potency of the TC as well as the amount of absorption. Various factors, which influence the absorption of the drug include factors such as potency of the TC, vehicle, site and frequency of application, duration of therapy, barrier function and condition of the skin. [3]


  Usage of tc in paediatric disorders Top


Any disease in children tends to affect the quality of life not only of the patient but also of the whole family. [4] Hence, TCs are used to produce quick symptomatic relief in distressing disorders such as atopic dermatitis, contact dermatitis, papular urticaria etc., The permeability of TC is more in infants and children due to the thinner skin and a higher skin area ratio in relation to their body weight. This is even more in premature infants who have a much thinner skin. The absorption can be further increased when the drug is applied under a diaper because of the occlusive effect of the diaper. The metabolism of the absorbed glucocorticoids is also less rapid in children and infants. The combination of excess absorption and less metabolism causes suppression of endogenous cortisol production. Under these circumstances, Addisonian crisis may occur if the topical steroid is suddenly stopped after prolonged therapy. Prolonged suppression of cortisol production may also cause growth retardation. Hence, TC of low potency applied over a limited area of skin for a short period of time are ideal for infants and children. [5],[6]

Permeability also depends on the amount of TC being applied. The use of the fingertip unit (FTU) may be helpful in guiding how much topical steroid is required to cover different areas of the body. The FTU is measured as the quantity of drug that can be expressed out of a tube with a nozzle of 5 mm diameter where the length of the drug extends from the distal crease of forefinger to the ventral aspect of fingertip. Counselling the parents of children regarding FTU may be helpful in preventing side effects caused by application of excess amounts of the drug. [7]

Tachyphylaxis has been observed in various disorders upon withdrawal of the drug. To prevent tachyphylaxis, gradual withdrawal with weekly intermittent therapy is often helpful. A regimen of reducing the twice daily to once daily application followed by intermittent therapy for 3 consecutive days with a gap of 4 consecutive days in a week before complete stoppage may be helpful. [8]

TCs should not be used for a prolonged period because long-term use of topical steroids can lead to various complications increasing the discomfiture of the already distressed child. [5]


  Adverse effects of tc in children Top


Adverse effects of TC depend on (a) chemical structure of the TC - TCs of higher potency have higher potential to produce side-effects (b) vehicle - while drugs in ointment bases have higher potential for absorption and side-effects, creams and lotions are absorbed less but may cause hypersensitivity reactions (c) factors related to the site of application such as thickness of the stratum corneum, humidity and density of hair follicles (d) frequency and method of application - too frequent or faulty methods of application increase the chances of side-effects. [3]

Due to the hyperproliferative effects of TCs atrophy, striae, telengiectasia, purpura, bruising and ulceration may occur. Although atrophy can be partially reversed, striae are irreversible. [3] In older children and adolescents, acneiform eruptions (steroid acne), perioral dermatitis and rosacea like rash may be caused or aggravated by TC. [9] Prolonged use may also lead to hypertrichosis and reversible hypopigmentation. Aggravation of fungal infections such as dermatophytosis (tinea incognito), pityriasis versicolor and candida albicans; bacterial infections such as impetigo, folliculitis and furunculosis; viral infections such as herpes simplex and molluscum contagiosum and parasitic infections such as scabies have been known to occur after continuous use of TCs. In infants granuloma gluteale infantum may occur if diaper dermatitis is treated with TC. [10] Systemic absorption may lead to iatrogenic Cushing's syndrome [11] and slowing of linear growth. [12] Aggravation of an inflammatory dermatosis or lack of response to TC may occur due to allergic contact dermatitis to the steroid molecule, the vehicle or the preservative. [13],[14] TCs of lower potency such as hydrocortisone or desonide (commonly used in children) have a higher potential of producing allergic contact dermatitis than the midpotent or superpotent TCs. [15] Steroid dependence manifested as burning and itching with dryness and erythema may occur when TCs are attempted to be withdrawn after prolonged use. [16]


  Safe use of tc in children Top


Apart from the pharmacology of the TCs the safe use of corticosteroids also depends on various other considerations including proper diagnosis of the disease and the attitude of the parents. TCs should be used judiciously and rationally as far as practically possible in order to avoid side effects and adverse drug reactions. They should not be used when the diagnosis is uncertain since they may mask the disease making it more difficult to arrive at a diagnosis. Even when the diagnosis is certain and their use is imperative, the lowest potency TC that is capable of controlling the disease should be used. It is also judicious to withdraw the drug as early as possible and substitute it with other drugs such as emollients, topical calcineurin inhibitors or antipruritic agents such as calamine. [17]

TCs are available as combination products with antibacterials or antifungals. Masking of disease or even aggravation may occur when such combinations are used in primary bacterial, viral or fungal infections. Such combinations may also lead to rapid improvement in signs and symptoms causing premature stoppage of application of the drug and recurrence of disease.

Hence they are either used with caution or even avoided in infective diseases in children. [18]

Various additional factors need to be taken into consideration while prescribing TCs to children. These include treatment of associated disorders as well as a planned withdrawal. Associated factors which influence the choice of steroids and duration of treatment include other diseases such as infections, condition of the skin (xerosis and maceration), climatic conditions (temperature and humidity) and ecological environment (e.g., plants and insects). As mentioned earlier, planned withdrawal by intermittent use and gradual substitution by drugs such as other immunomodulators and emollients helps in preventing side effects of TC. [19]

Counseling of parents plays an important role in the treatment with TCs. This includes explanation about the amount of drug, duration of application and avoidance of factors which may aggravate the disease or cause side-effects of the drug. Parents must be counseled about the amount of TC to be applied and the use of FTUs. [7] They must also be informed hat over-application may lead to disastrous consequences and hence strict compliance to the doctor's prescription and timely follow-up is absolutely imperative. In India, there is a laxity of control on chemists resulting in TCs being served as over the counter prescriptions. Taking advantage of this situation repeating prescriptions and sharing of prescriptions among friends and relatives is rampant in this country. Parents must be counselled about the dangers of these practices particularly in the context of their children.

They should also be informed about the side-effects of TCs so that they may be on the lookout for early signs of TCs. Stoppage of the TC and early treatment of such side-effects can prevent any permanent damage. [5]

Steroid phobia, due to misinformation and disinformation regarding corticosteroids in the print and electronic media, is rampant among the lay public. Anxious parents of diseased children tend to be more careful about the drugs being prescribed and may try to influence the use and choice of TC. [20] The steroid phobic parent must not be allowed to prevent the use of TC when it is necessary or force the clinician to prescribe a TC of lower potency than needed. [21]

Finally, a growing menace is the injudicious prescribing of TCs by non-dermatologists particularly general practitioners, practitioners of alternative medicine and quacks. Such prescriptions do not take into account any of the factors mentioned above. Similarly laymen such as friends, relatives, neighbors and salesmen selling medicines at the chemists as well as those working in pharmaceuticals form a bulk population who "advise" parents and patients regarding TCs. This tendency of injudicious use of TCs has led to a phenomenal increase in incidence of side-effects and steroid dependence.


  Conclusion Top


TCs are a boon when used judiciously but a bane when used inappropriately. Children with their soft and tender skin are more susceptible to the side-effects of TCs than adults. Hence, the chances of side effects are more in such a situation. TCs should be prescribed cautiously in children. Prescribers should take into account the potency of the TC, the amount and duration of therapy and most importantly the disease for which the drug is being prescribed. [22]

 
  References Top

1.Sulzberger MB, Witten VH. The effect of topically applied compound F in selected dermatoses. J Invest Dermatol 1952;19:101-2.  Back to cited text no. 1
[PUBMED]    
2.Burkhart G, Morrell D, Goldsmith L. Dermatological pharmacology. In: Brunton LL, Chabner BA, Knollmann BC, editors. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 12 th ed. New York: McGraw Hill; 2011. p. 1806-8.  Back to cited text no. 2
    
3.Warner MR, Carnisa C. Topical corticosteroids. In: Wolvrton SE, editor. Comprehensive Dermatologic Drug Therapy. Philadelphia: Saunders Elsevier; 2007. p. 595-624.  Back to cited text no. 3
    
4.Beattie PE, Lewis-Jones MS. An audit of the impact of a consultation with a paediatric dermatology team on quality of life in infants with atopic eczema and their families: Further validation of the Infants' Dermatitis Quality of Life Index and Dermatitis Family Impact score. Br J Dermatol 2006;155:1249-55.  Back to cited text no. 4
    
5.Saraswat A. Topical corticosteroid use in children: Adverse effects and how to minimize them. Indian J Dermatol Venereol Leprol 2010;76:225-8.  Back to cited text no. 5
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6.Leung DY, Bieber T. Atopic dermatitis. Lancet 2003;361:151-60.  Back to cited text no. 6
    
7.Long CC, Finlay AY. The finger-tip unit: A new practical measure. Clin Exp Dermatol 1991;16:444-7.  Back to cited text no. 7
    
8.Veien NK, Olholm Larsen P, Thestrup-Pedersen K, Schou G. Long-term, intermittent treatment of chronic hand eczema with mometasone furoate. Br J Dermatol 1999;140:882-6.  Back to cited text no. 8
    
9.Rathi SK, Kumrah L. Topical corticosteroid-induced rosacea-like dermatitis: A clinical study of 110 cases. Indian J Dermatol Venereol Leprol 2011;77:42-6.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.Al-Faraidy NA, Al-Natour SH. A forgotten complication of diaper dermatitis: Granuloma gluteale infantum. J Family Community Med 2010;17:107-9.  Back to cited text no. 10
    
11.Semiz S, Balci YI, Ergin S, Candemir M, Polat A. Two cases of Cushing's syndrome due to overuse of topical steroid in the diaper area. Pediatr Dermatol 2008;25:544-7.  Back to cited text no. 11
    
12.Wolthers OD, Heuck C, Ternowitz T, Heickendorff L, Nielsen HK, Frystyk J. Insulin-like growth factor axis, bone and collagen turnover in children with atopic dermatitis treated with topical glucocorticosteroids. Dermatology 1996;192:337-42.  Back to cited text no. 12
    
13.Baeck M, Chemelle JA, Terreux R, Drieghe J, Goossens A. Delayed hypersensitivity to corticosteroids in a series of 315 patients: Clinical data and patch test results. Contact Dermatitis 2009;61:163-75.  Back to cited text no. 13
    
14.Coloe J, Zirwas MJ. Allergens in corticosteroid vehicles. Dermatitis 2008;19:38-42.  Back to cited text no. 14
    
15.Seyfarth F, Elsner P, Tittelbach J, Schliemann S. Contact allergy to mometasone furoate with cross-reactivity to group B corticosteroids. Contact Dermatitis 2008;58:180-1.  Back to cited text no. 15
    
16.Saraswat A, Lahiri K, Chatterjee M, Barua S, Coondoo A, Mittal A, et al. Topical corticosteroid abuse on the face: A prospective, multicenter study of dermatology outpatients. Indian J Dermatol Venereol Leprol 2011;77:160-6.  Back to cited text no. 16
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17.Del Rosso J, Friedlander SF. Corticosteroids: Options in the era of steroid-sparing therapy. J Am Acad Dermatol 2005;53 1 Suppl 1:S50-8.  Back to cited text no. 17
    
18.Dhar S. Should topical antibacterials be routinely combined with topical steroids in the treatment of atopic dermatitis? Indian J Dermatol Venereol Leprol 2005;71:71-2.  Back to cited text no. 18
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19.Drake LA, Dinehart SM, Farmer ER, Goltz RW, Graham GF, Hordinsky MK, et al. Guidelines of care for the use of topical glucocorticosteroids. American Academy of Dermatology. J Am Acad Dermatol 1996;35:615-9.  Back to cited text no. 19
[PUBMED]    
20.Charman C, Williams H. The use of corticosteroids and corticosteroid phobia in atopic dermatitis. Clin Dermatol 2003;21:193-200.  Back to cited text no. 20
    
21.Bewley A, Dermatology Working Group. Expert consensus: Time for a change in the way we advise our patients to use topical corticosteroids. Br J Dermatol 2008;158:917-20.  Back to cited text no. 21
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22.Rathi SK, D'Souza P. Rational and ethical use of topical corticosteroids based on safety and efficacy. Indian J Dermatol 2012;57:251-9.  Back to cited text no. 22
[PUBMED]  Medknow Journal  



 
 
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