Chapter 16: Common Dermatologic Therapies
Routine Skin-Care Measures: Anti-inflammatories
Corticosteroids
Topical corticosteroids (TCS) are classified by their ability to cause vasoconstriction, which roughly parallels their anti-inflammatory ability. Class I are the strongest steroids, and Class VII are the weakest.
Practical Tips
- A general guide to steroid concentration by body site:
- Hands and feet: Class I & II
- Trunk, limbs: Class III-V
- Face and body folds (groin, axilla): Class VI-VII
- A few days of stronger-than-usual potency might be necessary for severe flares.
- The duration of treatment with a TCS will vary with the condition being treated. Patients should treat until completely clear. “Clear” means that the skin is no longer red or bumpy, but post-inflammatory pigment change might remain. For patients who have frequent flares of their skin condition, using the TCS twice weekly for maintencance can help prevent flares. The goal is to be “off” the TCS more than they are “on.”
*Note that ointments are often more potent than creams for the same medication
- Wet wraps can be helpful to hydrate the skin and increase the efficacy of topical corticosteroids.
For widespread eruptions:
- Apply emollient or topical steroid to the affected areas
- A pair of damp full body pyjamas
- Place a dry layer of clothes over top to prevent evaporation and heat loss.
- For smaller involved areas, such as the hands or feet a topical steroid can be applied and then covered with a damp sock or glove with a dry overlayer
- Occlusion with dressing such as Tegaderm, plastic wrap or non-breathable gloves is another way to increase the penetration of topical corticosteroids.
| Ultra High Potency | Class I | Betamethasone dipropionate 0.05% ointment
Clobetasol propionate 0.05% Halobetasol propionate 0.05% |
|---|---|---|
| High Potency | Class II | Betamethasone dipropionate 0.05% cream
Fluocinonide acetonide 0.01% |
| Medium Potency | Class III | Betamethasone valerate 0.1% ointment
Mometasone furoate 0.1% ointment |
| Class IV | Betamethasone valerate 0.1% cream
Triamcinolone acetonide 0.1% ointment Mometasone furoate 0.1% cream |
|
| Class V | Triamcinolone acetonide 0.1% cream and lotion | |
| Low Potency | Class VI | Desonide 0.05% cream or ointment Fluocinolone acetonide 0.01% oil |
| Class VII | Hydrocortisone acetate all strengths |
*Note that ointments are often more potent than creams for the same medication
Calcineurin Inhibitors
Topical calcineurin inhibitors (TCI) are a class of anti-inflammatory medication that do not have any risk of skin atrophy with prolonged use. They are therefore useful in areas of the body that may be at risk of this with topical corticosteroids such as the face, or when a topical anti-inflammatory is needed for long-term, ongoing maintenance therapy.
The two available calcineurin inhibitors are pimecrolimus 1% cream and tacrolimus 0.03% and 0.1% ointment. These are thought to be roughly equivalent to a mild-moderate TCS (pimecrolimus) and a moderate TCS (tacrolimus). They are generally not effective on thick skin.
Some patients experience a burning sensation when the TCI is first applied. Fortunately, the sensation decreases after continuous use over several days.
PDE4 Inhibitors
A newer non-steroid topical medication is topical crisabarole 2% ointment. Crisaborole is a phosphodiesterase-4 inhibitor with anti-inflammatory properties and has similar efficacy to the topical calcineurin inhibitors. It can also cause a warm/hot sensation for several minutes when applied to facial skin.
