| Abstract|| |
Topical corticosteroids (TCs) are the pillars of dermatotherapeutics. These drugs are the “magic molecules,” provided they are used judiciously and appropriately, following a rational prescription. On exhaustive literature search in multiple databases, we found a significant evidence favoring the use of TCs in atopic eczema, localized vitiligo, psoriasis, chronic hand eczema, and localized bullous pemphigoid. However, contrary to conventional wisdom, we did not find any high-level scientific evidence in support of prescribing TCs in cutaneous lichen planus, sarcoidosis, and seborrhoeic dermatitis. Besides, evidence clearly advocates judicious use of mild-to-moderate corticosteroids (if required) in pregnancy and lactation and there is no risk of any fetal abnormality.
Keywords: Meta-analysis, randomized controlled trials, systematic reviews, topical corticosteroids
|How to cite this article:|
Das A, Panda S. Use of topical corticosteroids in dermatology: An evidence-based approach. Indian J Dermatol 2017;62:237-50
What was known?
- Topical corticosteroids are the most commonly prescribed drugs by dermatologists in an outpatient setting
- TCs are being used since ages, in eczema, vitiligo, psoriasis, lichen planus, hand eczema, etc
- Topical steroid addiction or red burning skin syndrome is increasingly being recognized, due to illegitimate prescriptions by physicians.
| Introduction|| |
Since the introduction in early 1950s, topical corticosteroids (TCs) have become the most commonly prescribed drugs by dermatologists in an outpatient setting. These agents form the mainstay of treatment for many skin conditions. If used appropriately, they are safe and effective, and side effects are rare. Not only dermatologistsbut also steroids have been rampantly prescribed by quacks, general physicians, pediatricians, gynecologists, and specialists of innumerable disciplines.
Unfortunately, TCs are increasingly being abused by doctors and patients. Topical steroid addiction and red burning skin syndrome are legitimate clinical entities which are well recognized these days. Sometimes, these terms are used synonymously. As a result, the problem of steroid phobia is being increasingly recognized by physicians worldwide which, sometimes, is associated with simple fear, due to ignorance of the patient. In addition, current advice to patients to apply TC preparations “sparingly” or “thinly” contributes to steroid phobia, increasing the risk of poor clinical response, and treatment failure. Such cautionary advice also overlooks the fact that the vast majority of patients are prescribed TCs of mild potency for which the evidence suggests that the risk of harm is minimal. In the patient's mind, the current advice groups all steroids together regardless of their potential for adverse effects. The advice also tends to reinforce an erroneous concern that the risks from TCs may be similar to those from systemic corticosteroids.
In this article, we have reviewed the various indications of TCs in dermatology with an overview of the evidence available in support of using these drugs in various dermatoses. Wherever possible, we have tried our best to corroborate the evidence, and analyze them in such a manner that both the opposing concerns may be addressed, and we may come up with a balanced view on TC use in clinical dermatology. At the outset, we would like to summarise the levels of evidence. Level I suggests evidence from a systematic review of randomized controlled trials. Level II corroborates with evidence obtained from at least one well-designed Randomized Controlled Trial. Level III takes into consideration, evidences obtained from well-designed controlled trials without randomization. However, Level IV relates to well-designed case-control and cohort studies. Level V considers evidence from systematic reviews of descriptive and qualitative studies. Level VI and VII are poor quality evidences. Level VI considers evidence from a single descriptive or qualitative study and Level VII takes into account, opinion of authorities and/or reports of expert committees.
| Discussion and Evidence|| |
Eczema is a noninfective, chronic, inflammatory dermatological entity manifesting as inflamed, pruritic, erythematous, and/or asteatotic skin. Numerous therapeutic modalities are available to combat this notorious dermatosis, TCs being the most commonly prescribed ones. However, most of the patients show excellent response to emollients., According to the traditional school of thought, it is advisable to use TCs during acute episode and withdraw them, once the symptoms have been controlled. However, recent authors are of the opinion that proactive approach is better than the more commonly followed reactive approach. As per recent guidelines, it is favorable to use high-dose corticosteroids during the acute flares and continue with low-dose corticosteroids when the episode is under control.
Besides, step-up and step-down approach can be followed which refers to increasing the potency of the steroid in acute flares and lowering the potency in the periods of remission. Overall, a systematic review of the best strategies for using TCs in the treatment of established eczema is, therefore, required.
Here is a brief overview of some of the major randomized controlled trials (RCTs) comparing the use of different TCs in eczema [Table 1].
These studies showed significant improvement in 13%–100% of patients after 1–12 weeks of treatment. Most of the studies found significant improvement with TC in comparison with placebo. However, three studies could not demonstrate a significant difference between placebo and TC. Few RCTs showed that intermittent treatment with a potent TC could reduce the number of flare-ups. Three RCTs and two small randomized within-patient comparison studies have examined the use of wet-wrap bandaging applied over TC. To summarize, we are not in a position to recommend the “best” TC, as till now, not a single RCT has compared all the available preparations of TC of similar potency. Besides, there is no clear RCT evidence supporting the use of twice-daily over once-daily TC administration. However, it is now clear that application of twice-weekly potent TC to stable eczema can reduce the number of flare-ups in adults as well as children although the long-term safety profile of such intermittent or pulse therapy in infants, is absent.
In a systematic review of treatments for atopic eczema, RCTs of TCs collected data on thinning of the skin and suppression of pituitary – adrenal axis. These RCTs could not show any evidence of harm – although the studies were short-term. There is no RCT evidence that skin thinning is a problem with the correct use of TC although the fact that most RCTs are of short duration is a limitation in basing the conclusions solely on RCT-generated evidence in this regard, and other non-RCT evidence should be used to issue firm recommendations.
Vitiligo is an acquired pigmentary disorder, attributed to the destruction of melanocytes. Therapeutic modalities which are present include topical and systemic corticosteroids, topical calcineurin inhibitors, photo (chemo) therapy, vitiligo surgery, and depigmentation of normally pigmented skin. Immunosuppressive therapy with highly potent TCs (clobetasol) gives excellent results in cases of localized stable vitiligo.,,
Herein, we have tabulated the evidence available in favor of using TCs in vitiligo [Table 2].
A meta-analysis, an additional systematic review, and several RCTs showed that Class III TCs are effective in comparison with placebo, either alone or in combination with narrowband – ultraviolet B (UVB), or psoralen plus UVA light (using sunlight or artificial light sources), in treating generalized and localized vitiligo. There is some RCT evidence that topical clobetasol propionate is of equivalent effectiveness with tacrolimus in treating this condition. All studies examining the effect of TCs reported adverse effects, with the more frequent being atrophy, telangiectasia, hypertrichosis, and acneiform papules.
Topical steroids have been used since ages to manage mild-to-moderate plaque psoriasis (scalp and nonscalp). These are available in different potencies and formulations, but their use relies mostly on the basis of individual experience. Here is a brief summary of evidence in favor of using topical steroids in psoriasis [Table 3].,
|Table 3: Evidence in favor of using topical corticosteroids in psoriasis (nonscalp)|
Click here to view
To summarize, both Class III and Class IV TCs are effective in inducing remission in psoriasis; however, Class IV appears superior. It remains unclear whether once- or twice-daily dosing should be recommended, but frequency, as well as duration, should be tapered down in a maintenance phase because of concerns with cutaneous and systemic adverse effects of TCs. Skin atrophy is the most common complication, but it is less of an issue in psoriatics than atopics. However, the continuous use of very potent or ultrapotent TCs may cause irreversible skin atrophy and striae, may cause psoriasis to become unstable, and may have systemic effects when used over a large surface area. The ointment formulations appear to be the most effective, but there are many alternative galenicals to increase feasibility and treatment adherence without losing too much effectiveness of the drugs.
Scalp psoriasis, though, responds to a wide array of topical therapies but TCs form the first line of management, and the response is excellent., The evidence in favor of steroids has been tabulated [Table 4].
|Tables 4: Evidence in favor of using topical corticosteroids in psoriasis (scalp)|
Click here to view
The results in scalp psoriasis are similar to that seen in chronic plaque psoriasis elsewhere in the body.
Lichen planus (LP) is a common chronic inflammatory dermatosis associated with disrupted cell-mediated immunity. Cutaneous lesions are often extremely pruritic and require rigorous intervention. Symptomatic oral LP is painful, and complete healing is uncommon, which necessitates active intervention. TCs are conventionally used as first-line therapy in cutaneous LP, but high-level scientific evidence is conspicuous by its absence. However, TCs show good results in oral LP, and the evidence has been summarized below [Table 5].,,,
|Table 5: Evidence in favor of using topical corticosteroids in lichen planus|
Click here to view
There is no evidence in favor of prescribing TCs in cutaneous LP although it is widely accepted as the first-line treatment for the same. This an indicator of the fact that, like several other more uncommon inflammatory dermatoses, in LP too, the use of TCs is fairly undocumented, but not necessarily unwarranted, as the advent of TC as a group of agents happened in the age of empiricism when the use of medicines was dictated by hypothetical reasoning rather than being guided by evidence generated from RCTs.
Only limited evidence exists for the efficacy of TCs in oral LP. In addition, there is no evidence that topical calcineurin inhibitors are more effective than TCs in oral LP.
The most common form of cutaneous T-cell lymphoma is mycosis fungoides (MF), which accounts for approximately 60% of cases. Several reviews and guidelines on the management of MF have been published. TCs have been used in the treatment of mild, patch stage MF with good results, but unfortunately, evidence in favor of using them, is lacking. The current evidence-based recommendation is: TCs, especially Class I (potent) compounds, are effective at temporarily clearing patches and plaques in some patients with early-stage IA/IB MF.
Bullous pemphigoid (BP) is an acquired common autoimmune blistering dermatosis characterized by the development of autoantibodies against the components of the basement membrane zone of the skin. Interestingly, superpotent topical steroids have emerged as a first-line therapy for limited disease. Two randomized clinical trials have been published in favor of topical steroids, and the summary has been tabulated as under [Table 6].
|Table 6: Evidence in favor of using topical corticosteroids in bullous pemphigoid|
Click here to view
The two RCTs suggest the use of TCs as the first line for the treatment for both localized and mild disease. Relatively, few and mild side effects are associated with TC use in BP; however, their use in extensive disease may be limited by more side effects and practical factors.
Sarcoidosis is a granulomatous disease with multisystem involvement. Topical high potency fluorinated corticosteroids (with or without occlusive dressing) have been successfully used in localized cutaneous sarcoidosis, but high-level scientific evidence is lacking.,
Chronic hand eczema is an extremely common and notorious entity encountered by general physicians and dermatologists. Currently, evidence-based guidelines for the management of this condition is lacking. However, there a few randomized clinical trials favoring the use of TCs [Table 7].
|Table 7: Evidence in favor of using topical corticosteroids in hand eczema|
Click here to view
There is insufficient data on which to base a choice between short bursts of potent TCs compared with continuous application of mild TCs. There is little evidence of steroid-sparing effect of emollients. There is an insufficient evidence of an additive effect of topical antibacterial agents. In addition, there is a lack of data supporting the superiority of topical calcineurin inhibitors to TCs.
Superficial infantile cutaneous hemangiomas are difficult to manage. Two small case series using ultrapotent TCs for periocular hemangiomas have been reported. However, evidence in favor of using this therapy for other sites is lacking. Garzon et al . assessed the cessation of growth, shrinkage or flattening of the lesion, and lightening of the surface color. Seventy-four percent of the cases demonstrated either good or partial response to ultrapotent TCs. In another study by Pandey et al ., mometasone was applied twice daily and compared with intralesional triamcinolone acetonide injections at monthly intervals at 1–2 mg/kg. Topical steroids were found to be a good alternative to intralesional steroids for treating superficial hemangiomas.
| Miscellaneous Conditions|| |
One RCT demonstrated that potent TCs are marginally more effective than placebo when used continuously for a minimum of 3 months. In observational case series, children between the ages of 3 and 10 years appear most likely to respond.
In idiopathic cases, TCs may be helpful, but they may mask malignancy and other underlying disease.
Cutaneous lupus erythematosus
All the controlled trials of TC were of short duration, but the evidence supports the use of potent TCs in DLE (Discoid lupus erythematosus). Although TC use may be associated with skin atrophy, it is probably not important in DLE, which produces severe scarring and atrophy in itself.
There have been one systematic review  and one trial of 17 participants followed for 3 months. Although the study reports that betamethasone was effective as a depigmenting agent (P < 0.05), the numbers were very small, and seven of 16 women in the study found no therapeutic difference between treatment and placebo. There is controversy over the balance between benefits and harms of using TCs in the treatment of melasma, especially since long-term use on the face can cause skin thinning and telangiectasia.
There is insufficient evidence (level of evidence: D) on the effects of nonfluorinated steroids in patients with perioral dermatitis. A split-face RCT of hydrocortisone butyrate versus 1% hydrocortisone alcohol cream is available. Two patients with perioral dermatitis showed a moderate rebound of the eruption after withdrawal of topical treatment, in each case on the hydroxybutyrate-treated side of the face. In view of the study design and the small number of patients, it is difficult to draw conclusions.
Even though, TCs are considered to be the first line therapy for the management of seborrheic dermatitis, but, there is absence of high-level evidence supporting the use of TCs. Studies have shown that steroids are superior to placebo in the treatment of mild to moderate seborrheic dermatitis. Besides, there were no statistically significant differences between steroids and calcineurin inhibitors in terms of the assessed outcomes in a few studies. In addition, no statistically significant differences were found between steroids and azoles in their effectiveness in producing total clearance of lesions of seborrheic dermatitis.
| Pregnancy and Lactation|| |
Women with skin conditions often need TCs during pregnancy. However, the knowledge about the effects of TCs on the fetus is scarce. The current best evidence supports the use of mild-to-moderate TCs in comparison to potent/superpotent alternatives in pregnancy because of the associated risk of fetal growth restriction with the latter. There is no significantly increased risk of orofacial clefts, preterm delivery, growth retardation, and fetal death when mild-to-moderate TCs are used in pregnancy. However, it must be noted that potent or superpotent TCs should be used as second-line therapy only for the shortest possible duration. Whenever high potency corticosteroids are used, meticulous obstetric care is mandatory because they increase the likelihood of low birth weight baby. Depending on the severity of the dermatoses, women should use TCs of the least potency required, and the duration and amount of application of the drug must be monitored judiciously. The risk of adverse events is increased when areas with high absorption (genitals, eyelids, skin folds, armpits, and vulva) are treated with topical steroids. There is lack of evidence regarding the safety profile of newer lipophilic TCs (mometasone furoate, fluticasone propionate, and methylprednisolone aceponate) with a good therapeutic index. On theoretical grounds, these should be associated a lesser risk of low birth weight, but high-level scientific evidence is lacking, and it is not possible to comment on the adverse effect profile of these newer congeners.,,,
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fukaya M, Sato K, Sato M, Kimata H, Fujisawa S, Dozono H, et al.
Topical steroid addiction in atopic dermatitis. Drug Healthc Patient Saf 2014;6:131-8.
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.
Dirven-Meijer PC, Glazenburg EJ, Mulder PG, Oranje AP. Prevalence of atopic dermatitis in children younger than 4 years in a demarcated area in central Netherlands: The West Veluwe Study Group. Br J Dermatol 2008;158:846-7.
Oranje AP, de Waard-van der Spek FB, Ordonez C, De Raeve L, Spierings M, van der Wouden JC. Emollients for eczema (Protocol). Cochrane Database Syst Rev 2010;8:CD008304.
Grimalt R, Mengeaud V, Cambazard F; Study Investigators' Group. The steroid-sparing effect of an emollient therapy in infants with atopic dermatitis: A randomized controlled study. Dermatology 2007;214:61-7.
Bieber T. Atopic dermatitis. Ann Dermatol 2010;22:125-37.
Moed H, Yang Q, Oranje AP, Panda S, van der Wouden JC. Different strategies for using topical corticosteroids for established eczema (Protocol) Cochrane Database Syst Rev.2012;10:CD010080.
Almeyda J, Burt BW. Double blind controlled study of treatment of atopic eczema with a preparation of hydrocortisone in a new drug delivery system versus betamethasone 17-valerate. Br J Dermatol 1974;91:579-83.
Yasuda T. Clinical experiences with hydrocortisone 17-butyrate. Dermatologica 1976;152 Suppl 1:221-9.
Fisher M, Kelly AP. Multicenter trial of fluocinonide in an emollient cream base. Int J Dermatol 1979;18:660-4.
Lassus A. Clinical comparison of alclometasone dipropionate cream 0.05% with hydrocortisone butyrate cream 0.1% in the treatment of atopic dermatitis in children. J Int Med Res 1983;11:315-9.
Andersen BL, Andersen KE, Nielsen R, Stahl D, Niordson A, Roders GA. Treatment of dry atopic dermatitis in children. A double-blind comparison between mildison Lipocream™ (1% hydrocortisone) and Uniderm™ (1% hydrocortisone) ointment. Clin Trials J 1988;25:278-84.
Vernon HJ, Lane AT, Weston W. Comparison of mometasone furoate 0.1% cream and hydrocortisone 1.0% cream in the treatment of childhood atopic dermatitis. J Am Acad Dermatol 1991;24:603-7.
Rafanelli A, Rafanelli S, Stanganelli I, Marchesi E. Mometasone furoate in the treatment of atopic dermatitis in children. J Eur Acad Dermatol Venereol 1993;2:225-30.
Marchesi E, Rozzoni M, Pini P, Cainelli T. Comparative study of mometasone furoate and betamethasone dipropionate in the treatment of atopic dermatitis. G Ital Dermatol Venereol 1994;129:IX-XII.
Koopmans B, Lasthein Andersen B, Mork NJ, Austad J, Suhonen RE. Multicentre randomized double-blind study of locoid lipocream fatty cream twice daily versus locoid lipocream once daily and locobase once daily. J Dermatol Treat 1995;6:103-6.
Jorizzo J, Levy M, Lucky A, Shavin J, Goldberg G, Dunlap F, et al.
Multicenter trial for long-term safety and efficacy comparison of 0.05% desonide and 1% hydrocortisone ointments in the treatment of atopic dermatitis in pediatric patients. J Am Acad Dermatol 1995;33:74-7.
Bleehen SS, Chu AC, Hamann I, Holden C, Hunter JA, Marks R. Fluticasone propionate 0.05% cream in the treatment of atopic eczema: A multicentre study comparing once-daily treatment and once-daily vehicle cream application versus twice-daily treatment. Br J Dermatol 1995;133:592-7.
Wolkerstorfer A, Strobos MA, Glazenburg EJ, Mulder PG, Oranje AP. Fluticasone propionate 0.05% cream once daily versus clobetasone butyrate 0.05% cream twice daily in children with atopic dermatitis. J Am Acad Dermatol 1998;39(2 Pt 1):226-31.
Lebwohl M, Lane A, Savin R, Drake L, Berman B, Lucky A, et al
. A comparison of once-daily application of mometasone furoate 0.1% cream compared with twice-daily hydrocortisone valerate 0.2% cream in pediatric atopic dermatitis patients who failed to respond to hydrocortisone. Int J Dermatol 1999;38:604-6.
Prado de Oliveira ZN, Cuce LC, Arnone M. Comparative evaluation of efficacy, tolerability and safety of 0.1% topical momethasone furoate and 0.05% desonide in the treatment of childhood atopic dermatitis. An Bras Dermatol 2002;77:25-33.
Hanifin J, Gupta AK, Rajagopalan R. Intermittent dosing of fluticasone propionate cream for reducing the risk of relapse in atopic dermatitis patients. Br J Dermatol 2002;147:528-37.
Torok HM, Maas-Irslinger R, Slayton RM. Clocortolone pivalate cream 0.1% used concomitantly with tacrolimus ointment 0.1% in atopic dermatitis. Cutis 2003;72:161-6.
Kirkup ME, Birchall NM, Weinberg EG, Helm K, Kennedy CT. Acute and maintenance treatment of atopic dermatitis in children-two comparative studies with fluticasone propionate (0.05%) cream. J Dermatolog Treat 2003;14:141-8.
Beattie PE, Lewis-Jones MS. A pilot study on the use of wet wraps in infants with moderate atopic eczema. Clin Exp Dermatol 2004;29:348-53.
Hebert AA, Cook-Bolden FE, Basu S, Calvarese B, Trancik RJ; Desonide Hydrogel Study Group. Safety and efficacy of desonide hydrogel 0.05% in pediatric subjects with atopic dermatitis. J Drugs Dermatol 2007;6:175-81.
Msika P, De Belilovsky C, Piccardi N, Chebassier N, Baudouin C, Chadoutaud B. New emollient with topical corticosteroid-sparing effect in treatment of childhood atopic dermatitis: SCORAD and quality of life improvement. Pediatr Dermatol 2008;25:606-12.
Peserico A, Städtler G, Sebastian M, Fernandez RS, Vick K, Bieber T. Reduction of relapses of atopic dermatitis with methylprednisolone aceponate cream twice weekly in addition to maintenance treatment with emollient: A multicentre, randomized, double-blind, controlled study. Br J Dermatol 2008;158:801-7.
Glazenburg EJ, Wolkerstorfer A, Gerretsen AL, Mulder PG, Oranje AP. Efficacy and safety of fluticasone propionate 0.005% ointment in the long-term maintenance treatment of children with atopic dermatitis: Differences between boys and girls? Pediatr Allergy Immunol 2009;20:59-66.
Trookman NS, Rizer RL. Randomized controlled trial of desonlde hydrogel 0.05% versus desonide ointment 0.05% in the treatment of mild-to-moderate atopic dermatitis. J Clin Aesthet Dermatol 2011;4:34-8.
Rubio E, Martinez-Mir I, Morales-Olivas FJ, Aragones AM, Larrea VP, Sese AB. et. al
. Allergic diseases of the skin and drug allergies – 2015. Randomized controlled, double blind trial of topical twice weekly fluticasone propionate maintenance treatment to reduce risk of relapse in mild or moderate atopic dermatitis in children. The World Allergy Organization Journal. 2013;6(Suppl 1). p. 102.
Ruzicka T, Willers C, Wigger-Alberti W. Efficacy and patient-reported outcomes of a new mometasone cream treating atopic eczema. Skin Pharmacol Physiol 2012;25:305-12.
Thomas K, Charman C, Nankervis H, Ravenscroft J, Williams HC. Atopic eczema. In: Williams HC, Bigby M, Herxheimer A, Naldi L, Rzany B, Dellavalle RP, et al
., editors. Evidence-Based Dermatology. 3rd
ed. Chichester: Wiley Blackwell; 2014. p. 13-8.
Hoare C, Li Wan Po A, Williams H. Systematic review of treatments for atopic eczema. Health Technol Assess 2000;4:1-191.
Forschner T, Buchholtz S, Stockfleth E. Current state of vitiligo therapy – Evidence-based analysis of the literature. J Dtsch Dermatol Ges 2007;5:467-75.
Whitton ME, Pinart M, Batchelor J, Leonardi-Bee J, González U, Jiyad Z, et al.
Interventions for vitiligo. Cochrane Database Syst Rev 2015;2:CD003263.
Njoo MD, Spuls PI, Bos JD, Westerhof W, Bossuyt PM. Nonsurgical repigmentation therapies in vitiligo. Meta-analysis of the literature. Arch Dermatol 1998;134:1532-40.
Kandil E. Treatment of vitiligo with 0-1 per cent betamethasone 17-valerate in isopropyl alcohol – A double-blind trial. Br J Dermatol 1974;91:457-60.
Clayton R. A double-blind trial of 0-05% clobetasol proprionate in the treatment of vitiligo. Br J Dermatol 1977;96:71-3.
Khalid M, Mujtaba G, Haroon TS. Comparison of 0.05% clobetasol propionate cream and topical Puvasol in childhood vitiligo. Int J Dermatol 1995;34:203-5.
Westerhof W, Nieuweboer-Krobotova L, Mulder PG, Glazenburg EJ. Left-right comparison study of the combination of fluticasone propionate and UV-A vs. either fluticasone propionate or UV-A alone for the long-term treatment of vitiligo. Arch Dermatol 1999;135:1061-6.
Lepe V, Moncada B, Castanedo-Cazares JP, Torres-Alvarez MB, Ortiz CA, Torres-Rubalcava AB. A double-blind randomized trial of 0.1% tacrolimus vs. 0.05% clobetasol for the treatment of childhood vitiligo. Arch Dermatol 2003;139:581-5.
Agarwal S, Ramam M, Sharma VK, Khandpur S, Pal H, Pandey RM. A randomized placebo-controlled double-blind study of levamisole in the treatment of limited and slowly spreading vitiligo. Br J Dermatol 2005;153:163-6.
Lim-Ong M, Leveriza RM, Ong BE, Frez ML. Comparison between narrow-band UVB with topical corticosteroid and narrow-band UVB with placebo in the treatment of vitiligo: A randomized controlled trial. J Philippine Dermatol Soc 2005;14:17-25.
Kumaran MS, Kaur I, Kumar B. Effect of topical calcipotriol, betamethasone dipropionate and their combination in the treatment of localized vitiligo. J Eur Acad Dermatol Venereol 2006;20:269-73.
Sanclemente G, Garcia JJ, Zuleta JJ, Diehl C, Correa C, Falabella R. A double-blind, randomized trial of 0.05% betamethasone vs. topical catalase/dismutase superoxide in vitiligo. J Eur Acad Dermatol Venereol 2008;22:1359-64.
Sassi F, Cazzaniga S, Tessari G, Chatenoud L, Reseghetti A, Marchesi L, et al.
Randomized controlled trial comparing the effectiveness of 308-nm excimer laser alone or in combination with topical hydrocortisone 17-butyrate cream in the treatment of vitiligo of the face and neck. Br J Dermatol 2008;159:1186-91.
Wazir SM, Paracha MM, Khan SU. Efficacy and safety of topical mometasone furoate 0.01% vs. tacrolimus 0.03% and mometasone furoate 0.01% in vitiligo. J Pak Assoc Dermatol 2010;20:89-92.
Köse O, Arca E, Kurumlu Z. Mometasone cream versus pimecrolimus cream for the treatment of childhood localized vitiligo. J Dermatolog Treat 2010;21:133-9.
Yaghoobi R, Omidian M, Bagherani N. Original article title: “Comparison of therapeutic efficacy of topical corticosteroid and oral zinc sulfate-topical corticosteroid combination in the treatment of vitiligo patients: A clinical trial”. BMC Dermatol 2011;11:7.
Xing C, Xu A. The effect of combined calcipotriol and betamethasone dipropionate ointment in the treatment of vitiligo: An open, uncontrolled trial. J Drugs Dermatol 2012;11:e52-4.
Kathuria S, Khaitan BK, Ramam M, Sharma VK. Segmental vitiligo: A randomized controlled trial to evaluate efficacy and safety of 0.1% tacrolimus ointment vs. 0.05% fluticasone propionate cream. Indian J Dermatol Venereol Leprol 2012;78:68-73.
Akdeniz N, Yavuz IH, Gunes Bilgili S, Ozaydin Yavuz G, Calka O. Comparison of efficacy of narrow band UVB therapies with UVB alone, in combination with calcipotriol, and with betamethasone and calcipotriol in vitiligo. J Dermatolog Treat 2014;25:196-9.
Manriquez JJ, Niklitschek SM. Vitiligo. In: Williams HC, Bigby M, Herxheimer A, Naldi L, Rzany B, Dellavalle R. et al
., editors. Evidence-Based Dermatology. 3rd
ed. Wiley-Blackwell Publishers. 2014. pp.44-9.
Castela E, Archier E, Devaux S, Gallini A, Aractingi S, Cribier B, et al.
Topical corticosteroids in plaque psoriasis: A systematic review of efficacy and treatment modalities. J Eur Acad Dermatol Venereol 2012;26 Suppl 3:36-46.
Samarasekera EJ, Sawyer L, Wonderling D, Tucker R, Smith CH. Topical therapies for the treatment of plaque psoriasis: Systematic review and network meta-analyses. Br J Dermatol 2013;168:954-67.
Kuokkanen K. Comparison of 0.25% desoxymethasone ointment with 0.05% fluocinonide ointment in psoriasis. Curr Med Res Opin 1976;4:703-5.
Fabry H, Yawalkar SJ. A comparative multicentre trial of halometasone ointment and fluocortolone plus fluocortolone caproate ointment in the treatment of psoriasis. J Int Med Res 1983;11 Suppl 1:26-30.
Jegasothy B, Jacobson C, Levine N, Millikan L, Olsen E, Pinnell S, et al.
Clobetasol propionate versus fluocinonide creams in psoriasis and eczema. Int J Dermatol 1985;24:461-5.
Jacobson C, Cornell RC, Savin RC. A comparison of clobetasol propionate 0.05 percent ointment and an optimized betamethasone dipropionate 0.05 percent ointment in the treatment of psoriasis. Cutis 1986;37:213-4, 216, 218-20.
Blum G, Yawalkar S. A comparative, multicenter, double blind trial of 0.05% halobetasol propionate ointment and 0.1% betamethasone valerate ointment in the treatment of patients with chronic, localized plaque psoriasis. J Am Acad Dermatol 1991;25(6 Pt 2):1153-6.
Goldberg B, Hartdegen R, Presbury D, Smith EH, Yawalkar S. A double-blind, multicenter comparison of 0.05% halobetasol propionate ointment and 0.05% clobetasol propionate ointment in patients with chronic, localized plaque psoriasis. J Am Acad Dermatol 1991;25(6 Pt 2):1145-8.
Bernhard J, Whitmore C, Guzzo C, Kantor I, Kalb RE, Ellis C, et al.
Evaluation of halobetasol propionate ointment in the treatment of plaque psoriasis: Report on two double-blind, vehicle-controlled studies. J Am Acad Dermatol 1991;25(6 Pt 2):1170-4.
Katz HI, Gross E, Buxman M, Prawer SE, Schwartzel EH, Gibson JR. A double-blind, vehicle-controlled paired comparison of halobetasol propionate cream on patients with plaque psoriasis. J Am Acad Dermatol 1991;25(6 Pt 2):1175-8.
Olsen EA. Efficacy and safety of fluticasone propionate 0.005% ointment in the treatment of psoriasis. Cutis 1996;57 2 Suppl: 57-61.
Roberts DT. Comparison of fluticasone propionate ointment, 0.005%, and betamethasone-17,21-dipropionate ointment, 0.05%, in the treatment of psoriasis. Cutis 1996;57 2 Suppl: 27-31.
Sears HW. A double-blind, randomized, placebo-controlled evaluation of the efficacy and safety of hydrocortisone buteprate 0.1% cream in the treatment of psoriasis. Adv Ther 1997;14:140-9.
Peharda V, Gruber F, Prpic L, Kastelan M, Brajac I. Comparison of mometasone furoate 0.1% ointment and betamethasone dipropionate 0.05% ointment in the treatment of psoriasis vulgaris. Acta Dermatovenerol Croat 2000;8:223-6.
Stein LF, Sherr A, Solodkina G, Gottlieb AB, Chaudhari U. Betamethasone valerate foam for treatment of nonscalp psoriasis. J Cutan Med Surg 2001;5:303-7.
Green L, Sadoff W. A clinical evaluation of tazarotene 0.1% gel, with and without a high- or mid-high-potency corticosteroid, in patients with stable plaque psoriasis. J Cutan Med Surg 2002;6:95-102.
Lebwohl M, Sherer D, Washenik K, Krueger GG, Menter A, Koo J, et al.
A randomized, double-blind, placebo-controlled study of clobetasol propionate 0.05% foam in the treatment of nonscalp psoriasis. Int J Dermatol 2002;41:269-74.
Gottlieb AB, Ford RO, Spellman MC. The efficacy and tolerability of clobetasol propionate foam 0.05% in the treatment of mild to moderate plaque-type psoriasis of nonscalp regions. J Cutan Med Surg 2003;7:185-92.
Decroix J, Pres H, Tsankov N, Poncet M, Arsonnaud S. Clobetasol propionate lotion in the treatment of moderate to severe plaque-type psoriasis. Cutis 2004;74:201-6.
Lowe N, Feldman SR, Sherer D, Weiss J, Shavin JS, Lin YL, et al.
Clobetasol propionate lotion, an efficient and safe alternative to clobetasol propionate emollient cream in subjects with moderate to severe plaque-type psoriasis. J Dermatolog Treat 2005;16:158-64.
Koo J, Blum RR, Lebwohl M. A randomized, multicenter study of calcipotriene ointment and clobetasol propionate foam in the sequential treatment of localized plaque-type psoriasis: Short- and long-term outcomes. J Am Acad Dermatol 2006;55:637-41.
Jarratt MT, Clark SD, Savin RC, Swinyer LJ, Safley CF, Brodell RT, et al.
Evaluation of the efficacy and safety of clobetasol propionate spray in the treatment of plaque-type psoriasis. Cutis 2006;78:348-54.
Angelo JS, Kar BR, Thomas J. Comparison of clinical efficacy of topical tazarotene 0.1% cream with topical clobetasol propionate 0.05% cream in chronic plaque psoriasis: A double-blind, randomized, right-left comparison study. Indian J Dermatol Venereol Leprol 2007;73:65.
Mraz S, Leonardi C, Colón LE, Johnson LA. Different treatment outcomes with different formulations of clobetasol propionate 0.05% for the treatment of plaque psoriasis. J Dermatolog Treat 2008;19:354-9.
Tiplica GS, Salavastru CM. Mometasone furoate 0.1% and salicylic acid 5% vs. mometasone furoate 0.1% as sequential local therapy in psoriasis vulgaris. J Eur Acad Dermatol Venereol 2009;23:905-12.
Fleming C, Ganslandt C, Guenther L, Johannesson A, Buckley C, Simon JC, et al.
Calcipotriol plus betamethasone dipropionate gel compared with its active components in the same vehicle and the vehicle alone in the treatment of psoriasis vulgaris: A randomised, parallel group, double-blind, exploratory study. Eur J Dermatol 2010;20:465-71.
Nast A, Spuls P, Nijsten T. Treatment of psoriasis. In: Williams HC, Bigby M, Herxheimer A, Naldi L, Rzany B, Dellavalle R. et al
., editors. Evidence-Based Dermatology. 3rd ed. Wiley-Blackwell Publishers. 2014. pp.175-99.
Willis I, Cornell RC, Penneys NS, Zaias N. Multicenter study comparing 0.05% gel formulations of desoximetasone and fluocinonide in patients with scalp psoriasis. Clin Ther 1986;8:275-82.
Olsen EA, Cram DL, Ellis CN, Hickman JG, Jacobson C, Jenkins EE, et al.
A double-blind, vehicle-controlled study of clobetasol propionate 0.05% (Temovate) scalp application in the treatment of moderate to severe scalp psoriasis. J Am Acad Dermatol 1991;24:443-7.
Klaber MR, Hutchinson PE, Pedvis-Leftick A, Kragballe K, Reunala TL, Van de Kerkhof PC, et al.
Comparative effects of calcipotriol solution (50 micrograms/ml) and betamethasone 17-valerate solution (1 mg/ml) in the treatment of scalp psoriasis. Br J Dermatol 1994;131:678-83.
Katz HI, Lindholm JS, Weiss JS, Shavin JS, Morman M, Bressinck R, et al.
Efficacy and safety of twice-daily augmented betamethasone dipropionate lotion versus clobetasol propionate solution in patients with moderate-to-severe scalp psoriasis. Clin Ther 1995;17:390-401.
Franz TJ, Parsell DA, Halualani RM, Hannigan JF, Kalbach JP, Harkonen WS. Betamethasone valerate foam 0.12%: A novel vehicle with enhanced delivery and efficacy. Int J Dermatol 1999;38:628-32.
Feldman SR, Ravis SM, Fleischer AB Jr., McMichael A, Jones E, Kaplan R, et al.
Betamethasone valerate in foam vehicle is effective with both daily and twice a day dosing: A single-blind, open-label study in the treatment of scalp psoriasis. J Cutan Med Surg 2001;5:386-9.
Andreassi L, Giannetti A, Milani M; Scale Investigators Group. Efficacy of betamethasone valerate mousse in comparison with standard therapies on scalp psoriasis: An open, multicentre, randomized, controlled, cross-over study on 241 patients. Br J Dermatol 2003;148:134-8.
Pauporte M, Maibach H, Lowe N, Pugliese M, Friedman DJ, Mendelsohn H, et al.
Fluocinolone acetonide topical oil for scalp psoriasis. J Dermatolog Treat 2004;15:360-4.
Jarratt M, Breneman D, Gottlieb AB, Poulin Y, Liu Y, Foley V. Clobetasol propionate shampoo 0.05%: A new option to treat patients with moderate to severe scalp psoriasis. J Drugs Dermatol 2004;3:367-73.
Reygagne P, Mrowietz U, Decroix J, de Waard-van der Spek FB, Acebes LO, Figueiredo A, et al.
Clobetasol propionate shampoo 0.05% and calcipotriol solution 0.005%: A randomized comparison of efficacy and safety in subjects with scalp psoriasis. J Dermatolog Treat 2005;16:31-6.
Jemec GB, Ganslandt C, Ortonne JP, Poulin Y, Burden AD, de Unamuno P, et al.
A new scalp formulation of calcipotriene plus betamethasone compared with its active ingredients and the vehicle in the treatment of scalp psoriasis: A randomized, double-blind, controlled trial. J Am Acad Dermatol 2008;59:455-63.
Buckley C, Hoffmann V, Shapiro J, Saari S, Cambazard F, Milsgaard M. Calcipotriol plus betamethasone dipropionate scalp formulation is effective and well tolerated in the treatment of scalp psoriasis: A phase II study. Dermatology 2008;217:107-13.
van de Kerkhof PC, Hoffmann V, Anstey A, Barnes L, Bolduc C, Reich K, et al.
A new scalp formulation of calcipotriol plus betamethasone dipropionate compared with each of its active ingredients in the same vehicle for the treatment of scalp psoriasis: A randomized, double-blind, controlled trial. Br J Dermatol 2009;160:170-6.
Cribier B, Frances C, Chosidow O. Treatment of lichen planus. An evidence-based medicine analysis of efficacy. Arch Dermatol 1998;134:1521-30.
Cheng S, Kirtschig G, Cooper S, Thornhill M, Leonardi-Bee J, Murphy R. Interventions for erosive lichen planus affecting mucosal sites. Cochrane Database Syst Rev 2012;2:CD008092.
Lodi G, Carrozzo M, Furness S, Thongprasom K. Interventions for treating oral lichen planus: A systematic review. Br J Dermatol 2012;166:938-47.
Zakrzewska JM, Chan ES, Thornhill MH. A systematic review of placebo-controlled randomized clinical trials of treatments used in oral lichen planus. Br J Dermatol 2005;153:336-41.
Voûte AB, Schulten EA, Langendijk PN, Kostense PJ, van der Waal I. Fluocinonide in an adhesive base for treatment of oral lichen planus. A double-blind, placebo-controlled clinical study. Oral Surg Oral Med Oral Pathol 1993;75:181-5.
Rodstrom PO, Hakeberg M, Jontell M, Nordin P. Erosive oral lichen planus treated with clobetasol propionate and triamcinolone acetonide in orabase: A double-blind clinical trial. J Dermatol Treat 1994;5:7-10.
Hegarty AM, Hodgson TA, Lewsey JD, Porter SR. Fluticasone propionate spray and betamethasone sodium phosphate mouthrinse: A randomized crossover study for the treatment of symptomatic oral lichen planus. J Am Acad Dermatol 2002;47:271-9.
Campisi G, Giandalia G, De Caro V, Di Liberto C, Aricò P, Giannola LI. A new delivery system of clobetasol-17-propionate (lipid-loaded microspheres 0.025%) compared with a conventional formulation (lipophilic ointment in a hydrophilic phase 0.025%) in topical treatment of atrophic/erosive oral lichen planus. A Phase IV, randomized, observer-blinded, parallel group clinical trial. Br J Dermatol 2004;150:984-90.
Conrotto D, Carbone M, Carrozzo M, Arduino P, Broccoletti R, Pentenero M, et al.
Ciclosporin vs. clobetasol in the topical management of atrophic and erosive oral lichen planus: A double-blind, randomized controlled trial. Br J Dermatol 2006;154:139-45.
Yoke PC, Tin GB, Kim MJ, Rajaseharan A, Ahmed S, Thongprasom K, et al.
A randomized controlled trial to compare steroid with cyclosporine for the topical treatment of oral lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:47-55.
Laeijendecker R, Tank B, Dekker SK, Neumann HA. A comparison of treatment of oral lichen planus with topical tacrolimus and triamcinolone acetonide ointment. Acta Derm Venereol 2006;86:227-9.
Gorouhi F, Solhpour A, Beitollahi JM, Afshar S, Davari P, Hashemi P, et al.
Randomized trial of pimecrolimus cream versus triamcinolone acetonide paste in the treatment of oral lichen planus. J Am Acad Dermatol 2007;57:806-13.
Carbone M, Arduino PG, Carrozzo M, Caiazzo G, Broccoletti R, Conrotto D, et al.
Topical clobetasol in the treatment of atrophic-erosive oral lichen planus: A randomized controlled trial to compare two preparations with different concentrations. J Oral Pathol Med 2009;38:227-33.
Ghabanchi J, Bahri Najafi R, Haghnegahdar S. Treatment of oral inflammatory diseases with a new mucoadhesive prednisolone table versus triamcinolone acetonide paste. IRCMJ 2009;11:155-9.
Fazel N. Cutaneous lichen planus: A systematic review of treatments. J Dermatolog Treat 2015;26:280-3.
Le Cleach L, Chosidow O. Lichen planus. In: Williams HC, Bigby M, Herxheimer A, Naldi L, Rzany B, Dellavalle R. et al
., editors. Evidence-Based Dermatology. 3rd
ed. Wiley-Blackwell Publishers. 2014. pp.200-5.
Kim EJ, Hess S, Richardson SK, Newton S, Showe LC, Benoit BM, et al.
Immunopathogenesis and therapy of cutaneous T cell lymphoma. J Clin Invest 2005;115:798-812.
Trautinger F, Knobler R, Willemze R, Peris K, Stadler R, Laroche L, et al.
EORTC consensus recommendations for the treatment of mycosis fungoides/Sézary syndrome. Eur J Cancer 2006;42:1014-30.
García-Romero MT, Werth VP. Randomized controlled trials needed for bullous pemphigoid interventions. Arch Dermatol 2012;148:243-6.
Joly P, Roujeau JC, Benichou J, Picard C, Dreno B, Delaporte E, et al.
A comparison of oral and topical corticosteroids in patients with bullous pemphigoid. N Engl J Med 2002;346:321-7.
Joly P, Roujeau JC, Benichou J, Delaporte E, D'Incan M, Dreno B, et al.
A comparison of two regimens of topical corticosteroids in the treatment of patients with bullous pemphigoid: A multicenter randomized study. J Invest Dermatol 2009;129:1681-7.
Volden G. Successful treatment of chronic skin diseases with clobetasol propionate and a hydrocolloid occlusive dressing. Acta Derm Venereol 1992;72:69-71.
Baughman RP, Lower EE. Evidence-based therapy for cutaneous sarcoidosis. Clin Dermatol 2007;25:334-40.
Faghihi G, Iraji F, Shahingohar A, Saidat A. The efficacy of '0.05% Clobetasol +2.5% zinc sulphate' cream vs. '0.05% Clobetasol alone' cream in the treatment of the chronic hand eczema: A double-blind study. J Eur Acad Dermatol Venereol 2008;22:531-6.
Agarwal US, Besarwal RK. Topical clobetasol propionate 0.05% cream alone and in combination with azathioprine in patients with chronic hand eczema: An observer blinded randomized comparative trial. Indian J Dermatol Venereol Leprol 2013;79:101-3.
] [Full text]
Gola M, D'Erme AM, Milanesi N. Clinical efficacy of two topical corticosteroids in the management of chronic hand eczema. G Ital Dermatol Venereol 2015;150:293-6.
Christoffers WA, Schuttelaar ML, Coenraads PJ. Hand eczema. In: Williams HC, Bigby M, Herxheimer A, Naldi L, Rzany B, Dellavalle R. et al
., editors. Evidence-Based Dermatology. 3rd
ed. Wiley-Blackwell Publishers. 2014. pp.117-26.
Garzon MC, Lucky AW, Hawrot A, Frieden IJ. Ultrapotent topical corticosteroid treatment of hemangiomas of infancy. J Am Acad Dermatol 2005;52:281-6.
Pandey A, Gangopadhyay AN, Sharma SP, Kumar V, Gupta DK, Gopal SC. Evaluation of topical steroids in the treatment of superficial hemangioma. Skinmed 2010;8:9-11.
Olsen E, Hordinsky M, McDonald-Hull S, Price V, Roberts J, Shapiro J, et al.
Alopecia areata investigational assessment guidelines. National Alopecia Areata Foundation. J Am Acad Dermatol 1999;40(2 Pt 1):242-6.
Oztas MO, Oztas P, Onder M. Idiopathic perianal pruritus: Washing compared with topical corticosteroids. Postgrad Med J 2004;80:295-7.
Jessop S, Whitelaw D. Cutaneous lupus erythematosus. In: Williams HC, Bigby M, Herxheimer A, Naldi L, Rzany B, Dellavalle R. et al
., editors. Evidence-Based Dermatology. 3rd
ed. Wiley-Blackwell Publishers. 2014. pp.523-30.
Rajaratnam R, Halpern J, Salim A, Emmett C. Interventions for melasma. Cochrane Database Syst Rev 2010;7:CD003583.
Neering H. Treatment of melasma (chloasma) by local application of a steroid cream. Dermatologica 1975;151:349-53.
Sneddon I. A trial of hydrocortisone butyrate in the treatment of rosacea and perioral dermatitis. Br J Dermatol 1973;89:505-8.
Kastarinen H, Oksanen T, Okokon EO, Kiviniemi VV, Airola K, Jyrkka J. et. al. Topical anti-inflammatory agents for seborrhoeic dermatitis of the face or scalp. Cochrane Database of Systematic Reviews 2014;5:CD009446.
Chi CC, Kirtschig G, Aberer W, Gabbud JP, Lipozencic J, Karpati S, et al.
Evidence-based (S3) guideline on topical corticosteroids in pregnancy. Br J Dermatol 2011;165:943-52.
Chi CC, Mayon-White RT, Wojnarowska FT. Safety of topical corticosteroids in pregnancy: A population-based cohort study. J Invest Dermatol 2011;131:884-91.
Chi CC, Wang SH, Mayon-White R, Wojnarowska F. Pregnancy outcomes after maternal exposure to topical corticosteroids:A UK population-based cohort study. JAMA Dermatol 2013;149:1274-80.
Chi CC, Kirtschig G, Aberer W, Gabbud JP, Lipozencic J, Karpati S, et al.
Updated evidence-based (S2e) European Dermatology Forum guideline on topical corticosteroids in pregnancy. J Eur Acad Dermatol Venereol 2017. [Epub ahead of print].
What is new?
- Twice-weekly application of potent topical corticosteroids. (TCs) in stable eczema significantly reduces the number of flares. Moreover, skin thinning and suppression of the pituitary – adrenal axis are not seen if TCs are used judiciously and appropriately
- Class III TCs are highly effective in the management of generalized or localized stable vitiligo. Long-term use must be avoided because of the risks of steroid-induced adverse effects
- Both Class III and Class IV TCs are effective in inducing remission in psoriasis (both scalp and nonscalp)
- TCs are widely used as first.line therapy in cutaneous lichen planus. (LP), but high-level scientific evidence is categorically absent. There is not a single-randomized controlled trial. (RCT) supporting the use of TCs in cutaneous LP. However, there are evidence in favor of prescribing TCs in oral LP
- Interestingly, TCs have emerged as the first.line treatment for both localized and mild bullous pemphigoid
- In chronic hand eczema, TCs have been found to be beneficial, but the choice between short bursts of potent TCs versus continuous application of mild TCs, is difficult, due to lack of evidence
- Evidence in favor of using TCs in mycosis fungoides, cutaneous sarcoidosis, infantile hemangiomas, seborrhoeic dermatitis is lacking
- In pregnancy and lactation, mild.to.moderate TCs can be safely prescribed, without the fear of associated risk of preterm labor and fetal growth restriction, provided TCs are not applied for a long duration and over areas with high absorption rates. Potent or superpotent TCs should be used only as second-line therapy because of risk of developing low birth weight baby.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]