1 - TOPICAL CORTICOSTEROIDS Flashcards
Topical corticosteroid potency relates to the intensity of the topical corticosteroid clinical effect
True
The Stoughton Vasoconstriction Assay correlates topical corticosteroid potency well with clinical efficacy and is reproducible
True (although it only measures one aspect of topical corticosteroid effects - vasoconstriction)
The resultant clinical potency of a TCS preparation depends on 4 interrelated factors:
(1) structure of the corticosteroid molecule
(2) the vehicle
(3) concentration of the corticosteroid molecule
(4) characteristics of the skin onto which the TCS is applied
True
Hydrocortisone (cortisol) is the backbone of most TCS molecules
True
The removal, replacement, or masking of hydroxyl groups changes a given molecule’s lipophilicity, solubility, percutaneous absorption and glucocorticoid receptor binding activity
True
Clobetasol propionate is a superpotent topical corticosteroid
True (clobetasol binds more tightly to the glucocorticoid receptor)
Moisturisers are incorporated into the vehicle to retard transepidermal water loss
True
Moisturisers are incorporated into the vehicle to occlude the corticosteroid molecule
True
Moisturisers are incorporated into the vehicle to increase the flexibility of the skin
True
Emulsifying agents in the vehicle are required to create oil-in-water preparations such as creams and lotions
True (help to distribute the TCS molecule evenly on the skin surface)
Solvents in the vehicle in lotions, solutions, gels, and sprays create a less viscous product
True
Humectants are necessary in oil-in-water preparations (vehicle) to maintain the required water content
True
Solvents such as propylene glycol and ethanol affect the TCS molecule’s solubility in the vehicle and skin by affecting its percutaneous absorption
True (the net effect of propylene glycol is to enhance potency through increasing the percutaneous absorption)
Very occlusive vehicles enhance a TCS’s molecule’s percutaneous absorption probably by increasing the hydration of the stratum corneum
True (thus a TCS molecule in an ointment vehicle tends to be more potent than the same concentration of the molecule in a cream or lotion)
Penetration of the applied TCS correlates inversely with the thickness of the stratum corneum
True (condition of the skin affects bioavailability)
Penetration of TCS increases with inflamed or diseased skin
True
Penetration of TCS increases with increased hydration of the stratum corneum
True
Penetration of TCS increases with relative humidity
True (hence WET dressings)
Penetration of TCS increases with temperature
True (hence wet dressings are soaked in LUKEWARM water)
The stratum corneum may act as a reservoir for TCS for up to 5 days
True (this retention is TCS concentration and formulation dependent)
The vehicle is a highly engineered balance of numerous chemicals (1) emollients, (2) emulsifying agents, (3) humectants, (4) emulsion stabilisers and viscosity builders, (5) thickening, stiffening and suspending agents, (6) solvents, (7) preservatives, antioxidants and chemical stabilisers
True
Petrolatum is an occlusive moisturiser
True
Glycerin is a humectant moisturiser and solvent
True
Propylene glycol is a humectant moisturiser, solvent, and functions as a preservative, antioxidant and chemical stabiliser
True
Lanolin is an occlusive moisturiser and emulsifying agent
True
TCS have anti-inflammatory effects
True
TCS have anti-proliferative actions
True
TCS affects polymorphonuclear leukocytes (neutrophils) thus reducing their antibacterial capabilities
True
TCS affects monocytes and thus their fungicidal activity are diminished
True
TCS affects lymphocytes and the local skin immune system
True
TCS affects mast cell sensitisation and mediator release induced by IgE are inhibited
True
The anti-inflammatory properties of TCS are useful for dermatoses in which inflammation is a problem (atopic dermatitis and contact dermatitis), but can be deleterious for dermatoses in which inflammation is a useful host response (dermatophyte infection)
True
TCS reduce mitotic activity (anti-proliferative) in the epidermis, leading to flattening of the basal cell layer and thinning of the stratum corneum and stratum granulosum
True
TCS does not affect keratinocyte ultrastructure and the basement membrane
True
TCS promote atrophy of the dermis through inhibition of fibroblast proliferation and inhibits synthesis of both glycosaminoglycans and collagen
True
Loss of dermal glycosaminoglycans and TCS-induced vasoconstriction leads to reduced dermal volume
True
The antiproliferative and atrophogenic effects of TCS are helpful in proliferative dermatoses (psoriasis)
True (though these effects are injurious when TCS are used in the wrong disease, location, potency, or in excessive quantities)
The antiproliferative effects of TCS are both direct and glucocorticoid receptor mediated effects
True
TCS inhibits melanocytes pigment production
True (inflammation causes hyperpigmentation I.e. Post-inflammatory hyperpigmentation)
High-potency and Superpotent TCS can be used in scalp psoriasis and alopecia areata Twice daily for 2 weeks on, 1 week off
True
The adverse effects from TCS preparations are mostly from the TCS molecule
True (the vehicle can potentiate these adverse effects and cause additional problems)
The systemic effects of absorbed TCS include (1) suppression of HPA-axis, (2) iatrogenic Cushings’s syndrome, (3) growth retardation in infants and children
True (TCS molecules can be absorbed percutaneously in significant quantities and seems to involve gross misuse)
Epidermal atrophy (shiny, wrinkled, fragile skin with hypopigmentation, prominent vasculature, stellate pseudoscars, striae or purpura) is the most common local adverse effect of TCS
True (may be seen within the 1st 7 days of daily superpotent TCS application under occlusion, and is a risk factor for local atrophy from TCS within 2 weeks of daily use of less potent TCS or superpotent TCS without occlusion)
Steroid addiction/rebound syndrome is a local adverse effect of TCS and is characterised by initial improvement with a TCS, followed by lack of response after continued application, followed by a flare after TCS withdrawal
True (treated skin might appear atrophic and erythematous, and the patient reports burning sensation; frequently involves facial, genital or perianal skin)
Glaucoma/cataracts is a local adverse effect of TCS in ophthalmic preparations, but are rare from TCS applied to the eyelid skin
True
Allergic or irritant contact dermatitis can be a local adverse effect of TCS
True
Tachyphylaxis can be a local adverse effect of TCS
True
Facial hypertrichosis can be a local adverse effect of TCS
True
Folliculitis and miliaria can be a local adverse effect of TCS
True
Genital ulceration can be a local adverse effect of TCS
True
Granulosum gluteale infantum is a local adverse effect of TCS
True
Crusted/Norwegian scabies can be a local adverse effect of long term TCS
True
Exacerbation or increased susceptibility to bacterial, fungal and viral infections is a local adverse effect of TCS
True
Reactivation of Kaposi’s sarcoma is a local adverse effect of TCS
True (developed at the site of TCS application for erosive lichen planus)
Perioral dermatitis, Rosacea and acne is a local adverse effect of TCS
True
Delayed wound healing is a local adverse effect of TCS
True
Young age is a risk factor for systemic effect of TCS
True (children and infants have a greater skin surface-to-body volume ratio and may be less able to quickly metabolise corticosteroids; catch up growth is expected when TCS is discontinued)
Continuous long term treatment with a TCS preparation near puberty should be avoided as growth suppression may cause premature epiphyseal closure before catch-up growth can occur
True
Liver disease is a risk factor for systemic effects of TCS
True (systemic corticosteroids are metabolised in the liver)
Kidney disease is a risk factor for systemic effects of TCS
True (the kidneys excrete metabolised and unmetabolised corticosteroid)
The amount of corticosteroid applied is a risk factor for systemic effects of TCS
True
The extent of skin surface treated is a risk factor for systemic effects of TCS
True
Hydration of the skin (affecting potency of TCS) is a risk factor for systemic effects of TCS
True
Frequency of TCS application is a risk factor for systemic effects of TCS
True
Duration of TCS treatment is a risk factor for systemic effects of TCS
True
Potency of the TCS is a risk factor for systemic effects of TCS
True
The use of occlusion (affects potency of TCS) is a risk factor for systemic effects of TCS
True
Young age (infancy/childhood) is a risk factor for local atrophy from TCS
True
Potency of TCS is a risk factor for local atrophy from TCS
True
Use of occlusion is a risk factor for local atrophy from TCS
True
Location on the face, neck, axilla, groin, and upper inner thighs and pretibial locations is a risk factor for local atrophy from TCS
True
Daivobet (calcipotriene/betamethasone dipropionate) does not suppress HPA-axis function
True
Mild or moderate TCS are preferred to potent or very potent TCS in pregnancy
True (association of fetal growth retardation with potent/very potent TCS use)
TCS products should not be applied to the nipples before nursing
True
Local adverse effects to TCS occur more frequently than systemic adverse effects, but are generally uncommon
True
It has been reported that the incidence of local adverse effects from unoccluded TCS is low and roughly equal to that with vehicle alone
True
Significant atrophy and striae are generally seen many weeks or months of application
True
Most signs of cutaneous atrophy resolve by 1-4 weeks after discontinuation of the TCS, however striae are permanent
True
Perioral dermatitis is a classic example of addiction/rebound syndrome and usually occurs after chronic or potent TCS exposure on the face
True (the dermatitis is characterised by both eczema and acne in a perioral, and sometimes periocular distribution)
Treatment of perioral dermatitis involves tetracycline 500-1000mg daily followed by slow taper to 250mg daily for several weeks, and the TCS can be tapered using a non-fluorinated TCS such as 1% hydrocortisone acetate cream
True
TCS initially improve, but eventually exacerbate inflammatory conditions (acne, Rosacea) and infections (scabies and dermatophytoses I.e. Tinea incognito)
True
Steroid acne rebound phenomenon does not seem to happen when hydrocortisone 0.75% is compounded with 0.5% Sulfur
True
Allergic contact dermatitis to a TCS product should always be considered when a corticosteroid-sensitive dermatitis fails to respond or worsens after TCS therapy
True (the allergy may involve the vehicle or the TCS molecule)
Allergic contact dermatitis to a TCS product may involve the vehicle or the TCS molecule
True (confirmation requires patch testing and occasionally prick and intradermal testing)
Corticosteroids are currently divided into 5 groups based on cross-reactivity defined by patch testing:
Group A - Hydrocortisone type
Group B - Triamcinolone Acetonide type (Aristocort/Tricortone)
Group C - Betamethasone type
Group D1 - Betamethasone Dipropionate type (Diprosone)
Group D2 - Methylprednisolone Aceponate type (Advantan)
True (TCS can cross react within each group, but only rarely between groups)
Treatment of a TCS-induced allergic contact dermatitis involves choosing a TCS from a different cross-reactivity group
True
A patient with a delayed-type hypersensitivity to a TCS should be warned that there is a small but definite risk of a generalised reaction to systemic administration of that corticosteroid
True
The common screening TCS for Group A (Hydrocortisone type) on patch testing is Tixocortol pivalate
True (hydrocortisone acetate, methylprednisolone, prednisolone and prednisone are part of Group A)
The common screening TCS for Group B (Triamcinolone Acetonide type) on patch testing is Budesonide
True
The common screening TCS for Group C (Betamethasone type) on patch testing is Betamethasone
True (dexamethasone is part of Group C)
The common screening TCS for group D1 (Betamethasone Dipropionate type) on patch testing is Clobetasol propionate
True (Betamethasone valerate and Mometasone furoate are part of Group D1)
The TCS prototype and common screening TCS on patch testing for Group D2 (Methylprednisolone Aceponate type) is Hydrocortisone-17-butyrate
True
A proven regimen to prevent tachyphylaxis does not exist although BD application for 2 weeks on, then 1 week off is recommended because it seems easier for patients to remember
True
TCS may cause facial hypertrichosis
True
TCS may cause folliculitis
True
TCS may cause miliaria
True
The vehicle of a TCS preparation can potentiate the adverse effects of the TCS or cause local adverse effects of its own
True
Components of a TCS vehicle can cause itching, burning, stinging, urticaria, and irritant contact dermatitis
True
Benzoic acid in the vehicle can cause stinging
True
Cinnamic acid compound in the vehicle can cause stinging
True
Lactic acid in the vehicle can cause stinging
True
Urea in the vehicle can cause stinging
True
Emulsifiers in the vehicle can cause stinging
True
Formaldehyde in the vehicle can cause stinging
True
Sorbic acid in the vehicle can cause stinging
True
Propylene glycol in the vehicle can be very irritating
True
Alcohol in the vehicle can be very irritating
True
Acetone in the vehicle can be very irritating
True
Very occlusive vehicles can cause folliculitis, miliaria, and exacerbation of acne and rosacea
True
Propylene glycol is a well-known allergen commonly used in TCS vehicles
True (1 of most common)
Sorbitan sesquioleate is a well-known allergen commonly used in TCS vehicles
True (1 of most common)
Formaldehyde-releasing preservatives is a well-known allergen commonly used in TCS vehicles
True
Parabens is a well-known allergen commonly used in TCS vehicles
True
MCI-MI is a well-known allergen commonly used in TCS vehicles
True
Lanolin is a well-known allergen commonly used in TCS vehicles
True
Fragrance is a well-known allergen commonly used in TCS vehicles
True
Urea 10% has been shown to cause significant degradation of the TCS in certain preparations
True
Superpotent TCS (class I) is used when dermatoses is resistant to intermediate of high potency TCS
True
Superpotent (Class I) and high (Class II and III) potency TCS should not be used on the face, axillae, submammary area or groin
True
Superpotent (Class I) and high (Class II and III) potency TCS should be avoided in infants and children under 12 years
True
Avoid extensive application of Superpotent (Class I) and high (Class II and III) potency TCS
True
Superpotent (Class I) and high (Class II and III) potency TCS is ideal in thick, lichenified, or hypertrophic skin
True (should be avoided in thin skin)
Superpotent (Class I) and high (Class II and III) potency TCS is for short term use only, ideally 2-3 weeks at a time
True
Intermediate (Class IV and V) potency TCS is used in moderately severe dermatoses
True
High (Class II and III) potency TCS is used in severe dermatoses
True
Intermediate (Class IV and V) potency TCS is best for short treatment of extensive dermatoses
True
Avoid extended use (> 1-2 weeks) of Intermediate (Class IV and V) potency TCS in infants and children
True
Intermediate (Class IV and V) potency TCS is best used on the trunk and extremities
True
Intermediate (Class IV and V) potency TCS is safer for short term use on thin skin, but is less effective on thicker skin
True
Low (Class VI and VII) potency TCS is used in steroid sensitive dermatoses
True
Low (Class VI and VII) potency TCS is the preferred treatment of large areas
True
Low (Class VI and VII) potency TCS is best if long term treatment is required
True
Low (Class VI and VII) potency TCS is best choice for face, axilla, groin, and other moist occluded areas
True
Low (Class VI and VII) potency TCS is ideal in infants and children
True
Low (Class VI and VII) potency TCS is best for thin skin, but not effective on thicker skin
True
Ointment is a water in oil emulsion vehicle
True
Cream is an oil in water emulsion vehicle
True
Gel is a cellulose cut with alcohol or acetone vehicle
True
Lotion is an oil in water vehicle
True
Solution is an alcohol-based vehicle
True
Ointment provides very good skin hydration
True
Cream is moderate in skin hydration potential
True
Gel, lotion and solution are drying
True
Ointment is best for thick, lichenified or scaly dermatoses
True
Cream is best for acute, subacute or weeping dermatoses
True
Gel, lotion and solution are best for scalp or dermatoses in dense hair areas
True
Ointment is best for thick palmar or plantar skin, and to be avoided with naturally occluded areas
True
Cream is good for moist skin and intertriginous areas
True
Gel is best for naturally occluded areas, scalp and mucosa
True
Lotion and solution are best for naturally occluded areas and scalp
True
Ointment is very greasy
True
Cream, gel, lotion and solution are cosmetically elegant
True (in contrast to ointment)
Ointment has a low potential for irritation
True
Cream has a variable potential for irritation and requires preservatives
True
Gel, lotion and solution have higher potential for irritation
True
Superpotent (Class I) TCS:
(1) Clobetasol propionate 0.05% (Clobex) ointment/cream/lotion
(2) Betamethasone dipropionate 0.05% (Diprosone) OV ointment/cream
True
High (Class II and III) potency TCS:
(1) Betamethasone dipropionate 0.05% (Diprosone, Eleuphrat) ointment/cream/lotion
(2) Betamethasone valerate 0.1% (Betnovate “full strength”) ointment/cream
(3) Methylprednisolone aceponate 0.1% (Advantan) fatty ointment/ointment/cream/lotion
(4) Mometasone furoate 0.1% (Elocon, Novasone) ointment/cream/lotion
True
Intermediate (Class IV and V) potency TCS:
(1) Betamethasone valerate 0.05% (Betnovate 1/2, Cortival 1/2) ointment/cream
(2) Betamethasone valerate 0.02% (Celestone M, Antroquoril) ointment/cream; (Betnovate 1/5, Cortival 1/5) cream
(3) Triamcinolone acetonide 0.02% (Aristocort, Tricortone) ointment/cream
(4) Clobetasone butyrate 0.05% (Eumovate) cream
True
Low (Class VI and VII) potency TCS:
(1) Desonide 0.05% (Desowen) lotion
(2) Hydrocortisone O.5% (Dermaid) cream/soft cream
(3) Hydrocortisone 1% (Dermaid) cream/soft cream
(4) Hydrocortisone 1% and Clioquinol 1% (Hydroform) cream
(5) Hydrocortisone acetate 1% (Sigmacort, Cortic-DS) ointment/cream; (Cortef) spray
True
