Topical Steroid Therapy Shireen Velangi Consultant Dermatology Queen Elizabeth Hospital Birmingham UK
Aim of the Workshop Non Dermatologists (Dermatologists should go to the Professors panel now!) To increase confidence in using topical steroid therapy in the management of vulval skin disorders To prescribe the correct strength of topical steroid in the right vehicle for the correct length of time to lead to clinical improvement Adjuvant topical management Potential pitfalls
How does a topical steroid work? Specific receptor to form a steroid-receptor complex Lipocortin produced suppresses prostaglandins and leukotrienes Inhibits recruitment of inflammatory cells into the skin
Effect of topical steroid on the skin Anti-inflammatory Immunosuppressive Anti-proliferative Vasoconstrictive
Which Topical Steroid should I use? What is in the topical steroid preparation I want to use? Where do I want to use it? Does the diagnosis affect which preparation I use?
What is in a topical steroid preparation? Active Drug (Steroid) Vehicle Excipients Preservatives Penetration enhancers fragrances
Topical Steroid Classification System
Should I use an ointment, cream or lotion? Ointment Greater absorption, more potent Best for thick, lichenified or scaly dermatoses Greasy but less potential for irritation Cream Best for weeping dermatoses, moist skin and flexures Preservatives may be irritant Lotions, Gel, (foam) and solutions Drying and may be irritant Useful in hair bearing skin
Fragrances Stearyl alcohol Propylene glycol Lanolin Chlorocresol Parabens Undeclared Excipients in Topical steroids
What about in Vulval Dermatoses? Hair bearing skin Occluded site Flexural thin skin Erosions and fissures
How strong and which formulation?
Lichen sclerosus Superpotent or potent Ointment preferable Once daily for one month Alternate days for one month Twice weekly 30g per 3 months maintenance
Superpotent or Potent Ointment preferable 5% lidocaine ointment may be required to gain tolerance Lichen Planus
Vulval Crohn s Disease Superpotent Ointment Once daily until fissures heal
Mild to moderate Cream when acute Red, weeping excoriations Ointment when chronic Dry, scaly fissures Lichen simplex Potent Break itch/scratch cycle Vulval Eczema
Mild to moderate Ointment Increased absorption Rebound flare Topical tar and calcipotriol Vulval Psoriasis
When should I use a combination product? No proven advantage risk of sensitisation Patient preference Risk of superinfection Multiple erosions Fissures Acute flare Seborrhoeic Dermatitis
How much should I advise the patient to use?
How often should topical steroids be used and for how long? Beware of steroid phobia Once daily until control Encourage compliance Package insert Photo or diagrams Advise when to use 30g to last 3-6 months Control cf cure
How much topical steroid is safe to use? Local side effects rare Adrenal Axis suppression Not in vulval disease alone Children Superpotent or potent 30g to last 6 months Safe during pregnancy Long-term use of an ultrapotent topical steroid for the treatment of vulval lichen sclerosus is safe. Kai A, Lewis F. J Obstet Gynaecol 2016;36(2):276-7
Should I advise patients to use anything else along with the topical steroid? Care of the vulva http://www.bad.org.uk/for-the-public/patient-information-leaflets/care-ofvulval-skin Avoidance of irritants and wet wipes Soap substitutes and emollients 30minutes before or after topical steroid Barrier creams if incontinence is an issue
Irritant Contact Dermatitis plus Psoriasis Avoidance of irritants Soap Substitute and emollient Zinc and castor oil ointment as barrier Medical management of incontinence Moderate potent topical steroid +/- antibacterial
How to Avoid Potential Pitfalls Non Compliance explanation Inadvertent overuse Photographs/diagram Vasoconstriction improves symptoms Contact allergic dermatitis Minimise excipients and antimicrobials Steroid induced rosacea Avoid overuse and transfer to normal skin Superinfection Look for clues
Take Home Messages If used correctly topical steroid therapy is effective in vulval skin disorders Tailor your choice of topical steroid according to the patient and their diagnosis Take the to explain where, how much and how often to use the treatment and be aware of conflicting advice from other health professionals/internet Be aware of the potential side effects of topical steroid therapy and how to recognise/avoid them
Other topical immunosuppressants