Topical Corticosteroids (TCS): Use and Misuse

Corticosteroids are a group of molecules released by an endocrine gland called adrenal gland. So it's clear that corticosteroids are produced by our body and they have a very important role to play in health and disease. Philip Hench was awarded Nobel Prize in medicine in 1950 for demonstrating the therapeutic value of cortisone (factor E) derived from animal adrenal cortex in management of rheumatoid arthritis. Sulzberger and Witten (1952) demonstrated the therapeutic value of hydrocortisone (factor F) ointment in management of eczema. We must realize that prior to this discovery, there was no reliable safe method to treat eczema and there used to be wards in hospitals where eczema cases used to be admitted and their limbs were splinted to prevent them from scratching and damaging their skin! With modifications in the structure of hydrocortisone molecule, more potent versions were soon created.

Uses

Topical corticosteroids (TCS) are the preparations applied on skin to treat the disease. These are indicated in a variety of inflammatory skin condition like atopic dermatitis, psoriasis, lichen planus, vitiligo, contact dermatitis, lichen sclerosus, insect bite reaction to mention a few. In atopic dermatitis these are first line treatment.

Advantages

One can target the disease affected skin without subjecting the other systems to the exposure of the drug. By being available in a variety of forms like cream, lotion, ointment, gel, spray, foam, shampoo etc, these can be applied to various parts of the body. By choosing the potency and concentration judiciously, TCS can be offered for tough to treat areas, sensitive skin regions and all age groups. TCS are elegant, effective in small quantities, are compatible with other medicines, and need to be applied less often.

Drawbacks and adverse effects

TCS are not a panacea and does not cure many of above mentioned conditions. these can get absorbed through skin and hence can have a systemic effect. Absorption is more in thin skin areas like face and body folds, in infants and children, when applied on inflamed skin and obviously when applied over larger areas. This can lead to systemic side effects like cushing's syndrome, suppression of endogenous steroid production, growth retardation in children, reduced calcium density in bones, cataract and glaucoma. TCS can cause side effects on skin like thinning, growth of unwanted hair over treated areas, striae, acne like and rosacea like lesions, hypopigmentation, TCS dependence/ addiction syndrome etc.

What's new in the formulation of TCS

There are TCS molecules that are not easily absorbed through the skin due to character of such molecules or the vehicle (base) in which these are delivered to skin. thus reducing risk of systemic absorption. There are also molecules which upon absorption through the skin are inactivated quickly by liver before they have a chance to cause systemic side effects.

Misuse

It has many reasons. To mention some of these:

• The tendency to ask the neighbouring chemist shop owner, a friend or relative for a 'tube' of a product to solve a 'skin issue.' Just because the advice is free, it doesn't become best advice. One has to pay later through adverse effects.
• To use steroids for treatment of acne, 'blemishes' and for getting 'fairer'. Cases of patients buying an unlabeled product from a beautician are common. These may be a TCS squeezed from a labelled tube which has been surreptitiously repackaged.
• Getting educated by 'internet university' and considering hydrocortisone as a TCS and using superpotent TCS without any worries as these don't have names ending with cortisone. Hydrocortisone is the mildest TCS which is licensed for OTC sale in countries with stringent laws about sale of medicines.
• Lax laws allowing formulations with a hotch-potch combination of superpotent TCS, antifungal agents, antibacterial agents and even antiparasitic agents!
• Lax dispensing laws allowing for no punishment in cases where TCS is sold without a prescription and where after a prescription is written once, the product is sold repeatedly, sometimes for years!
• Inadequate training to medical professionals at graduation level in view of dermatology being a subject of relatively low priority.
• Mixopathy practice where a physician trained in ayurvedic and homoeopathic branch of medicine are allowed to prescribe TCS.

What's needed to prevent misuse?

As one can see, this requires a combined effort on part of the government, medical professionals, the pharmaceutical industry, the chemist shop owners and over and above the citizens to create a scenario where the ethical use of TCS can improve the quality of life of patients, a 'steroid phobia' can be removed and where the misuse of TCS can hopefully be prevented.

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