Topical corticosteroids
Place in Therapy
Place in Therapy: Topical Corticosteroids
Topical corticosteroids, particularly hydrocortisone as an over-the-counter product, are usually considered as second or third line therapy only in moderate to severe cases of diaper dermatitis. Most of the existing evidence supporting the use of topical corticosteroids is for severe diaper dermatitis. The issue with topical corticosteroids is the lack of primary literature supporting their efficacy in the treatment of this dermatological condition. Most of the literature discusses the safety concerns associated with systemic absorption of these agents. However, there is one clinical trial that showed topical corticosteroids to be an effective treatment option with faster resolution when compared to zinc oxide and eosin.<1> There have been no studies comparing any topical corticosteroids to placebo for the treatment of diaper dermatitis. Although the primary evidence is lacking, there are numerous tertiary sources that recommend low potency topical corticosteroids (i.e. hydrocortisone) in the treatment of diaper dermatitis under specific circumstances.<2-5> Tertiary sources such as Patient Self Care by the Canadian Pharmacist Association will recommend its use with antifungal treatment if necessary.<2> However, it should be noted that only low potency corticosteroids should be used with antifungal treatment.<2-6>
There are many safety concerns regarding the use of topical corticosteroids which include both local (atrophy of the skin) and systemic (Cushings syndrome) effects.<2-6> There are case reports that link the use of high potency corticosteroids to the development of Cushing's syndrome when used in diaper dermatitis.<6> This is primarily due to the fact that infant skin is much thinner than adults, that infants are more sensitive to the effects of corticosteroids, and that the occlusive nature of the diaper increases the absorption of topical corticosteroids.<2-6> All these factors lead to the increase in systemic absorption which may result in potentially fatal Cushing's syndrome.<6> Although the only topical corticosteroid available is hydrocortisone 0.5%, which is both low in potency and in concentration, there is still the increased risk of serious adverse effects.
Therefore, as a result of limited primary literature and the concerns outlined in the more abundant tertiary literature on the efficacy and safety of these products, topical corticosteroids should be reserved for strict circumstances. These include low potency (hydrocortisone 0.5-1%) and short duration (1-2 weeks).<2-5> Along with this criteria, topical corticosteroids should only be used under the supervision of a physician.<2-5>
References
1. Arad A, Mimouni D, Ben-Amitai D, Zeharia A, Mimouni M. Primary literature: Efficacy of topical application of eosin compared with zinc oxide paste and corticosteroid cream for diaper dermatitis. Dermatology. 1999;199(4):319-22.
2. Sibbald, D. Diaper Dermatitis. In: McLeod PJ, Allen M, Conly J, eds. Patient Self-Care - Helping Your Patients Make Therapeutic Choices. 2nd ed. Ottawa, ON: Canadian Pharmacists Association; 2010: 534-545.
3. Humphrey S, Bergman JN, Au S. Practice Management Strategies for Diaper Dermatitis. Skin Therapy Letter. 2006 September. 11(7):1-6.
4. Pray SW. Appropriate Use of Non-prescription Hydrocortisone. US Pharm. 2009;34(4):12-15.
5. Borkowski, S. Diaper Rash Care and Management. Pediatr Nurs. 2004;30(6):467-470.
6. Semiz S, Balc YS, Ergin S, Candemir M, Polat A. Two cases of Cushing's Syndrome Due to Overuse of Topical Steroid in the Diaper Area. Pediatric Dermatology. 2008. 25(5):544-47.
7. Ward DB, Fleischer AB, Feldman SR, Krowchuk DP. Characterization of diaper dermatitis in the United States. Arch Pediatr Adolesc Med. 2000; 154:943-46.
Topical corticosteroids, particularly hydrocortisone as an over-the-counter product, are usually considered as second or third line therapy only in moderate to severe cases of diaper dermatitis. Most of the existing evidence supporting the use of topical corticosteroids is for severe diaper dermatitis. The issue with topical corticosteroids is the lack of primary literature supporting their efficacy in the treatment of this dermatological condition. Most of the literature discusses the safety concerns associated with systemic absorption of these agents. However, there is one clinical trial that showed topical corticosteroids to be an effective treatment option with faster resolution when compared to zinc oxide and eosin.<1> There have been no studies comparing any topical corticosteroids to placebo for the treatment of diaper dermatitis. Although the primary evidence is lacking, there are numerous tertiary sources that recommend low potency topical corticosteroids (i.e. hydrocortisone) in the treatment of diaper dermatitis under specific circumstances.<2-5> Tertiary sources such as Patient Self Care by the Canadian Pharmacist Association will recommend its use with antifungal treatment if necessary.<2> However, it should be noted that only low potency corticosteroids should be used with antifungal treatment.<2-6>
There are many safety concerns regarding the use of topical corticosteroids which include both local (atrophy of the skin) and systemic (Cushings syndrome) effects.<2-6> There are case reports that link the use of high potency corticosteroids to the development of Cushing's syndrome when used in diaper dermatitis.<6> This is primarily due to the fact that infant skin is much thinner than adults, that infants are more sensitive to the effects of corticosteroids, and that the occlusive nature of the diaper increases the absorption of topical corticosteroids.<2-6> All these factors lead to the increase in systemic absorption which may result in potentially fatal Cushing's syndrome.<6> Although the only topical corticosteroid available is hydrocortisone 0.5%, which is both low in potency and in concentration, there is still the increased risk of serious adverse effects.
Therefore, as a result of limited primary literature and the concerns outlined in the more abundant tertiary literature on the efficacy and safety of these products, topical corticosteroids should be reserved for strict circumstances. These include low potency (hydrocortisone 0.5-1%) and short duration (1-2 weeks).<2-5> Along with this criteria, topical corticosteroids should only be used under the supervision of a physician.<2-5>
References
1. Arad A, Mimouni D, Ben-Amitai D, Zeharia A, Mimouni M. Primary literature: Efficacy of topical application of eosin compared with zinc oxide paste and corticosteroid cream for diaper dermatitis. Dermatology. 1999;199(4):319-22.
2. Sibbald, D. Diaper Dermatitis. In: McLeod PJ, Allen M, Conly J, eds. Patient Self-Care - Helping Your Patients Make Therapeutic Choices. 2nd ed. Ottawa, ON: Canadian Pharmacists Association; 2010: 534-545.
3. Humphrey S, Bergman JN, Au S. Practice Management Strategies for Diaper Dermatitis. Skin Therapy Letter. 2006 September. 11(7):1-6.
4. Pray SW. Appropriate Use of Non-prescription Hydrocortisone. US Pharm. 2009;34(4):12-15.
5. Borkowski, S. Diaper Rash Care and Management. Pediatr Nurs. 2004;30(6):467-470.
6. Semiz S, Balc YS, Ergin S, Candemir M, Polat A. Two cases of Cushing's Syndrome Due to Overuse of Topical Steroid in the Diaper Area. Pediatric Dermatology. 2008. 25(5):544-47.
7. Ward DB, Fleischer AB, Feldman SR, Krowchuk DP. Characterization of diaper dermatitis in the United States. Arch Pediatr Adolesc Med. 2000; 154:943-46.