Topical Steroid Concerns (Part 1) - The power and pitfalls

While topical steroids are indispensable in dermatology, understanding their powers and pitfalls is essential for healthcare professionals. Listen along to hear: 

• The impact of topical steroids on the skin barrier, from the thinning of the stratum corneum to the disruption of the all-important “acid mantle”. 
• Insights into the accelerated absorption from long-term use and its consequences in the deeper layers of the dermis. 
• Considerations for children, exploring absorption rates in relation to their body surface area to weight ratio. 
• How the language we use can increase the risk of poor clinical response and treatment failure. 
• The statistics around steroid allergies, and how this is often underrecognised. 
• How the immune suppressing effect of topical steroids can be a real problem in the presence of skin infections.

Tune in for valuable insights that balance the power and pitfalls of topical steroids, the dermatological cornerstone for managing so many skin conditions. 

Thank you to our kind sponsor AproDerm, who provide a comprehensive range of quality emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis. 

To simplify the process of finding the most suitable emollient for each patient, they have developed a remarkable solution: the AproDerm Emollient Starter Pack. This pack conveniently combines all four of their emollients in a single prescription, enabling patients to identify their ideal emollient more efficiently, aiding both compliance and adherence. 

Find out more: https://aproderm.com/aproderm-emollient-starter-pack/ 

LI: https://www.linkedin.com/company/fontus-health-ltd/ 

Thank you for listening. We hope you find this podcast interesting and helpful, please leave us a review or email [e-mail] with any feedback on this episode or suggestions for what you would like to hear about in future podcasts. 

The views expressed in this podcast are of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated, or been involved in the programme, materials, or delivery of educational content. 

Episode Transcript

(00:08):
Hello and welcome again to thisRash Decisions podcast, where
we look at skin-related issues,conditions and treatments in an
interesting and informative way.
I'm Dr Roger Henderson, I've beena GP in the NHS for almost 40 years
and have a long-standing interestin this particular area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I'venow retired from my practice.

(00:30):
And I'm a primary care advisorto the National Eczema Society,
and I'm a former Chair of theDermatology Council for England.
Now, for those of you that have beenkind enough to have followed us for many

(00:51):
episodes of Rash Decisions, and we thankyou for that, you may remember that George
and I talked about the prescribing oftopical steroids in a previous podcast,
and George and I put our heads together tolook at topical steroids in more detail,
and I think in particular, some of theproblems that we can associate with their
use, both in primary and secondary care.

(01:14):
And I think that both George and I aregoing to put a fairly heavy caveat here
about today's podcast, and declare rightup front that we are both huge fans of
topical steroids, and I don't think I'mout of place saying that, am I George?
Absolutely not, no.
I really want it to be very clearthat, although we're coming up
with some of the negative issueswith topical steroids, I couldn't

(01:37):
practise dermatology without them.
And they are the cornerstone of managingso much unpleasant skin disease.
The vast majority of patients whouse a topical steroid gain enormous
benefit from them and experienceno significant side effects.
So it's really important we makethat point right from the outset,

(01:58):
that we are not anti topical steroidsby any stretch of the imagination.
But they do have problems.
Absolutely, and I think to anyhealthcare professional listening
to us, if they haven't prescribed atopical steroid today, they've probably
prescribed them in the last few days.
And I suspect they may not have giventoo much thought, because they are

(02:20):
so used to prescribing them and usingthem, about the potential impact.
So, let's start right at the top of thelist here, George, where we might look
at topical steroids biting back a little.
Not everyone might be aware thatthey weaken the skin barrier to
start with, and I think that theydo that in all sorts of ways.

(02:42):
The skin does start to thin and bucklea little bit from the outset, and
that's a factor I think that becomeseven more important when we take into
account the age of the person thatwe're putting those steroids onto.
Well that's the thing that all ourpatients, I think, are very aware of.
They say they don't want to use asteroid because it will thin the skin.
Yeah.
And they are right.

(03:04):
It does thin the skin and itdoes weaken that skin barrier.
This barrier is so important.
It is the protection of our body fromthis hostile world that we live in.
Without it, we would die in afew hours, from dehydration.
But it also stops bacteria and otherpathogens and allergens getting through.

(03:24):
But topical steroids reduce the numberof cell layers in the epidermis and
that can start after six weeks ofsteroid use and in some cases can
happen in as little as two weeks.
Wow.
Which is where the barrier is.
And if you think about it, manypatients with eczema have, with moderate
eczema, have nine flares a year,each flare treated with steroids for

(03:48):
between two and four weeks at least.
If you've got severe eczema, 11flares a year, you can see how people
end up being on topical steroidsfor very long periods of time, and
they will get thinning of the skin.
Furthermore, when they're absorbedthey reduce the collagen levels in the
dermis, and collagen is important asa supporting structure for both the

(04:13):
skin but also for blood vessels, sowhen that's damaged you get striae,
and you then bruise more easily.
What I think many people don'tknow, is that steroids raise the
pH of the surface of the skin.
We normally have a really importantacid mantle, and that acid mantle has
antibacterial properties, killing badbacteria and interestingly, favouring

(04:36):
the adhesion of healthy bacteria.
But it also controls the activityof the proteases that the skin makes
to break down the skin barrier.
If you raise the skin surface pH from5.5 to 7.5, you increase the activity
of the important proteases by 50%.

(04:57):
So you start breakingthe skin down faster.
Steroids also degranulate thestratum granulosum layer of the
skin, just below the stratum corneum.
And it's the stratum granulosumthat is making the skin barrier.
It's making the filaggrin thatchanges the shape of the cells.
The filaggrin then forms the naturalmoisturising factors that hold the

(05:19):
moisture in the stratum corneum.
It's the granules that make thetonofilaments that form the rods
that change the shapes, and thenconnect to the corneodesmosomes.
It's the stratum granulosum thatproduces the desmosin, the enzyme
that changes the weak bonds deeperin the skin, the desmosomes, into

(05:40):
the strong corneodesmosome bonds.
And it's the granules that producethe lipid lamella envelope, the
oily material full of ceramidesand phospholipids and things that
fill the spaces between the cells.
So, when you degranulate,you can't do any of that.
And the skin barrier becomesa much more deficient barrier.

(06:01):
Steroids break protein down.
These corneodesmosomes are protein bonds.
You break those bonds further.
And all these problems are greater wherethe skin barrier is at its weakest.
But that is where you get eczema.
And that is where you put your steroids.
And as you said, it's older peoplewith thinner skin and infants with

(06:23):
very thin skin who are even morevulnerable to this skin thinning effect.
So yeah, it's not normally a problem ifyou keep to short courses of steroids,
but if you end up needing them for longperiods of time, they will significantly
weaken that skin barrier, and they willcause more problems, and thin the skin.

(06:45):
Yeah, it's interesting.
When I was doing my dermatologytraining in the early 80s as a medical
student, it was almost still in thedays of, the philosophy was, if it's
wet, dry it, if it's dry, wet it.
That's it, that's your dermatology learnt.
But one enlightened specialist, Iremember, did tell me about topical
steroids, and they did talk aboutthe weakening of the skin barrier.

(07:06):
But they then linked it into howquickly topical steroids are absorbed
and I remember them saying, thiscan be something of a double whammy,
because you're thinning the epidermis,they're really easily absorbed.
So the longer you use them for, thefaster they're absorbed, and that then
causes more problems in the dermis.

(07:26):
It's almost like aCatch-22 with chronic use.
And I don't think they were wrong, do you?
You couldn't have put it better.
Absolutely.
Most topical steroids arerelatively small molecules.
They're under 500 Daltons.
So, that's the size that canpenetrate through the skin.

(07:47):
And on the thin skin areas I've beentalking about, for example, the face,
which is generally where eczema occurs.
It occurs on thin skin areas and wherethe topical steroids are being used.
Up to 30% of a topical steroidis absorbed through the skin.
And as I've just said, in the veryyoung and the very old, or when the skin

(08:08):
barrier is damaged, as for example, ineczema, that absorption is even greater.
By thinning the epidermis, thesteroids, as you say, increase
the penetration of that topicalsteroid, causing more problems
deeper in the skin, in the dermis.
As your teacher taught you 40 years ago.

(08:29):
But they also get absorbed systemically,and this becomes particularly relevant
in infants who have a very large bodysurface area to body weight ratio.
In an older person, your skinis relatively less of your body
size than it is in an infant.
You suppress thehypothalamic-pituitary-adrenal axis.

(08:50):
And that's really important to bearin mind, because if you then stop
the potent topical steroids suddenly,they can have a problem because their
steroid production can be compromised.
But it also begins to cause otheruntoward steroid-associated side effects.
So it is a potential cause of concernand it's something we do need to be

(09:10):
aware of, particularly with potenttopical steroids being used on thin
skin areas, particularly in infants.
The Catch-22 we talked about, the thinningof the skin, allied to the increased
absorption, which increases as the skinthins even more, I think can also apply

(09:30):
as another Catch-22, to healthcareprofessionals listening to this, who
may over the years have just developeda slight wariness about using topical
steroids for understandable reasons.
But it's almost swung the pendulumtoo far and I think that they are
sometimes misguided or well-intentioned.

(09:54):
The advice that we give to our patientsmeans that ultimately we end up underusing
them and being between a rock and a hardplace, because the skin problem doesn't
really get better, doesn't automaticallyget worse, but we just tick along.
But we're not giving theamount that we need to.
Yeah, and I think that's possibly abigger problem than overusing them.

(10:19):
Yeah.
The packaging on steroids says 'usesparingly', or the prescription is written
[like] that, or the pharmacist saysthat, or it says 'avoid broken skin'.
Hang on, eczema is broken skin.
And they come back to the physicianwith an undertreated dermatosis that
would have responded beautifullyto adequate topical steroid, but

(10:43):
of course it's not being controlledand that is incredibly frustrating.
You're trying to undothose myths and concerns.
That's where I'm really keen to getthis balance, that we must make sure
that people don't overuse them forlong periods of time in the wrong
areas, but equally aren't too afraidto use them when they're so wonderful.

(11:04):
They really do work brilliantly.
And it's so frustrating foreveryone, including the doctors,
and the patient who continues toexperience ongoing skin problems.
It is very difficult to undo someof that misinformation, and often
very well-intentioned but misguidedinformation that's passed on.
Absolutely.
And the term 'use sparingly', Ithink it's a classic example of

(11:27):
language and words between healthcareprofessionals and patients.
So, if you use 'sparingly' to a patient,just give him a steroid and just tell
them to go off and use it sparingly.
What does that mean?
To some patients that'll meanthey slap a tube on in a day.
To others they will just put alittle tiny dab on once a week and
be terrified that they've overusedit, so you have to be very careful

(11:50):
with the language that you use.
And that's why we talked lasttime about fingertip units.
Exactly.
Because then we have a universal systemfor being very clear about the quantity
that we expect to be used, but we canreference our previous podcast on that.
But I'm sure like you, I've seenpatients return with their creams
and ointments, which I asked them todo, and it was prescribed 6/12 months

(12:11):
ago, and it has barely been touched.
And that's the only tube they'vebeen given and you say I wonder
why it's not getting better.
That's right.
And that's a good tip, ask them tobring their medication back with
them, and that tends not to lie.
If I think about something else thatperhaps people listening to us might not

(12:35):
twig about topical steroids, because italmost seems counterintuitive, because
you're reducing skin inflammationwith topical steroids and things
are settling down, is the incidenceof allergies to topical steroids.
And I do think this can be a bitof an elephant in the room, that we
just don't realise the numbers canbe really quite significant here.

(12:58):
I've even had patients tell me they'vebeen to see a dermatologist who said
allergy to steroids doesn't exist.
They are wrong.
Yeah.
It was first described in the lastcentury and it's now well-documented and
probably much more common than recognised.
In fact, studies from Europe and theUSA have shown the incidence from
patch test clinic patients rangesfrom just 0.5% to over 10%, 10.7%.

(13:24):
So there's certainly a measurablenumber of patients who are allergic.
And so if you put that topicalsteroid on, you're causing
contact allergic dermatitis.
The other thing to bear in mind isthat, I generally, as I said in that
last podcast, prefer to use ointments.
Because ointments have virtuallyno water and then therefore
don't need preservatives.
But creams have a high watercontent and so they do need

(13:48):
preservatives and other ingredients.
And allergy to these is evenmore common than allergy to
the topical corticosteroids.
So if you use ointments, yourpatient's less likely to run
into an allergic problem.
But, as you can imagine, adding more ofa topical steroid to the skin to somebody
who's got an established contact allergyto that, you're just adding fuel to the

(14:11):
fire and will make things much worse.
Agreed.
And talking of making things much worse,amongst all the things we have to think
about in a busy 10 minute consultation,if we are lucky enough to have 10
minutes, is to consider whether you'regoing to affect the immunity of someone

(14:35):
you're putting the topical steroids on.
Immune suppression can be a reallyfantastic impact of topical steroids.
It's one of the reasons we use them.
It's great.
But on the other side of the coin,if you've got some infections, immune
suppression can be an absolute disaster.
So that's another thing, just to thinkabout, when we're prescribing these.

(14:56):
Yeah, topical steroids are very broadspectrum, immune suppressing agents,
and as you say, that's great in thecontext of an inflammatory condition
like eczema, where the immune systemis driving all that inflammation.
But in the presence of infection,you need that inflammation.

(15:16):
And significant infections in the skin,like, for example, fungal infections,
these are normally contained by the bodyin the top layer, in the stratum corneum.
If you add a steroid, you stop theskin's ability to keep it there, and the
fungus grows down deeper into the dermis.
And here, the topical treatmentsthat normally help with fungal skin

(15:37):
infections, when they're on thesurface, no longer help at all.
In addition, it begins to look differentand is more difficult to diagnose.
It has less of the scales.
It begins to look disguised.
So we call this tinea incognito.
But other infections, notably tuberculosison the skin, if you put a steroid on

(15:58):
that, you can also make that go wrong.
In addition to that, there are a numberof conditions that I've never seen in
somebody who's never used a steroid.
A classic example wouldbe perioral dermatitis.
I've never seen a case of that insomebody where a steroid hasn't
been exhibited to the skin insome form, often inadvertently.

(16:18):
So 'periorificial' is the proper namebecause it occurs around the eyes
as well, but it's normally aroundthe mouth, so perioral dermatitis
is driven by topical steroids.
Of course, the topical steroids arecalming it down at the same time,
so you're in a vicious cycle againthat you want to put more steroids
on to calm it down, but that'sonly going to make it even worse.

(16:39):
And I've seen people going up the ladderof topical steroids until they end up
on a potent topical steroid, and thenthey're really seriously out of control.
And rosacea is another example where youdo not want steroids to get near the skin.
Even inhaled steroids, or trivial amountsfrom treating a child as a caregiver,
washing your hands, thinking you'regetting it all off, but there's a residue

(16:59):
there that then gets onto your face.
It can drive perioraldermatitis and rosacea.
And to anyone who hasn't listened toour episode on rosacea, I do suggest
you give it a listen because Georgeand I cover that in great detail and
we had some great feedback to it.
So if you haven't listenedto that particular episode,
then do give it a visit.

(17:20):
And I think before we go, we reallymust return to our opening statement
that we are not anti topical steroids.
We just feel that we need to be alertto the possibility that they can
cause problems and then continue toenjoy using them for those conditions
where they are absolutely brilliant.
I think that's an appropriate placeto bring this particular episode to a
close, and George and I do hope thatyou found it interesting and helpful.

(17:45):
There's one condition we haven't mentionedin this podcast, which is Topical Steroid
Withdrawal Syndrome, a dreadful skindisease with quite a lot to discuss.
So, we're actually going todevote a whole podcast to that.
And we very much hope you'll be able tojoin us next time when we'll be joined
by an ambassador for this condition,Briana Banos, who herself has suffered

(18:08):
from Topical Steroid Withdrawal Syndrome,knows what it feels like and will be able
to discuss in detail with us the patientexperience and this dreadful condition.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Rash Decisions podcasts together.
We couldn't have done it without them.
If you're enjoying listening to thesepodcasts as much as George and I enjoy

(18:32):
making them, then do rate and review usbecause it really does help us in putting
them together and send us your feedback.
We do love to hear from you.
So, until the next time,it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.