There is much more to prescribing topical steroids than meets the eye and we ignore these other factors at our peril
Dr Carol Cunningham
Since the development of topical steroids in the 1940s, the management of skin disease has been revolutionised. Glucocorticoid or synthetic steroid containing cream, lotion or ointment targets the inflammatory cells in the skin where it is needed – thus largely avoiding the side effects of long term systemic steroids.
The concept is simple, yet there is often more to prescribing topical steroids than meets the eye! How often do we reflect on the following factors when we reach for the prescription pad: prescriber experience; patient beliefs, concerns, expectations, preference, understanding, motivation and adherence; societal and social media influences? We ignore these at our peril.
Assuming that we have prescribed the correct topical steroid treatment, how many of us are confident that the steroid we have prescribed will be applied appropriately by the patient or their carer? After all, 30-50 per cent of patients do not take prescribed medication.
There are multiple potential pitfalls along the way – starting with the prescriber. Firstly, how competent are we in prescribing the appropriate potency steroid in an appropriate base (ointment, cream, lotion, gel, foam), for the appropriate body site to be applied with appropriate frequency and of adequate duration. We can learn more about how best to prescribe steroids by reading NICE (National Institute for Clinical Excellence) guidance, undertaking primary care dermatology courses and reading BAD (British Association of Dermatologists) guidelines. Assuming we have cleared this first hurdle, we then consider whether the prescribed treatment will be on the hospital or local dispensary formulary. Assuming it is, will it be dispensed exactly as prescribed? Thirdly, we must consider factors pertaining to the patient and their social circumstances as these are likely to be overlooked in a rushed consultation. We cannot however easily appreciate a patient’s perspective without getting “inside their skin” .
In the first consultation with a new eczema patient we must start on a long journey; walking alongside the patient in order to understand their perspective. We must ask about previous experience of topical steroid- have they developed well established habits which need to be broken, have they abandoned topical treatment altogether? If so, it is worth questioning why? Frequently cited reasons are that the consistency of the preparation is unacceptable, or it is too time consuming to apply. It is important to probe in this manner and ascertaining whether a therapeutic course of treatment has been completed before dismissing a treatment as “ineffective” – frequently the topical treatment has not been applied as intended. This highlights the importance of investing time and using clear communication to achieve maximum patient adherence.
In some cases, a “steroid phobia” – a misnomer for steroid avoidance or non-adherence – has developed through well-intentioned self-education on social media. Patients or their carers may have been poorly advised by an inexperienced clinician, pharmacist or family members. Transference of a fear of steroid side effects may occur which erodes patients’ confidence in steroid treatments.
“Steroid withdrawal syndrome”, “red skin syndrome” and “topical steroid addiction” are all synonyms for a newly promoted theory which is promoted by the web-based Support group ITSAN (International Topical Steroid Addiction Network) which claims that topical steroid use worsens eczema and is to be strictly avoided. It is possible that in some individuals applying topical steroid (particularly potent types) over prolonged period may develop persistent erythema (not steroid induced telangiectasia) which in these patients often affects the face and/or genitalia. After months or years of treatment, such patients report that eczema appears to rebound or reflare (sometimes worse than pre-treatment) during or sometimes after topical (and sometimes systemic) steroid treatment has been stopped. This concept is not accepted officially by the dermatology community nor is it mentioned in eczema guidelines. The studies reporting the condition are of poor quality and there is much speculation about whether it actually exists. If it is a true entity, it likely reflects topical steroid misuse or overuse– it is not an inevitable consequence of intermittent topical steroid use which is appropriately applied in those with chronic eczema. Unfortunately, ITSAN does not make a clear distinction between the two nor does it acknowledge that there is a large body of evidence to support the effective and safe use of long term intermittent course of topical steroids.
ITSAN poses a real challenge for clinicians managing eczema in patients whose faith in topical steroid treatment has been destroyed. It is important that dermatologists and general practitioners are aware of the movement and the resultant steroid avoidance among our patient followers which is sometimes not openly declared. If we do not enquire about social media and other influences among our tech savvy patients we may find ourselves switching from one topical steroid to another in vain only to realise none of it is being applied because our patient has adopted an anti-steroid stance inspired by sheer terror of becoming addicted and dependent on topical steroid. Part of the problem is failure to manage expectations – eczema treatment is not a quick fix and sometimes the disease flares despite appropriate treatment. The requirement for longterm treatment of a condition that is often chronic, disheartens patients who then seek refuge on online forums – sometimes because they don’t feel they can express their frustration openly with their clinician within the confines of a 10 minute appointment. The role of the GP is crucial here – building up rapport over a number of visits and feeding back to the Dermatologist when it becomes apparent that the patient does not wish to have topical steroids any longer.
Overzealous patients may “overtreat” eczema with inappropriately potent steroids which may be due to lack of education from their GP or dermatologist, resulting in steroid induced rosacea, perioral dermatitis, steroid atrophy and striae. In some cases, there may even be demonstrable adrenal insufficiency due to systemic absorption.
Finally, there are two groups of patients in whom we may even need to avoid certain topical steroid classes altogether: those who have chronic side effects of steroid overuse; and those with contact dermatitis (allergic or irritant) and other form of immune mediated reactions (angioedema, erythema multiforme) are more likely to develop in those in whom topical steroid has been applied for prolonged periods and in older patients. Clues to the diagnosis are: chronic relapsing eczema especially on face, hands and legs; lack of improvement despite increasing the potency of steroid used and worsening of eczema following application.
The solution? Patch testing screens for contact allergy/irritancy to steroid by testing patients to tixocortol pivalate and budesonide (part of the European Standard Series). For example, patients with tixocortol pivalate allergy will need to avoid hydrocortisone and prednisolone- fluocinolone acetonide is a synthetic hydrocortisone derivative and is a safe alternative.
Alternatives to topical steroid therapy in those who cannot or will not apply topical steroids include calcineurin inhibitor therapy with tacrolimus (0.1 per cent or 0.03 per cent) or pimecrolimus provided eczema is not too acutely inflamed. In such patients, calcineurin inhibitors must be avoided until significant erythema and oedema has reduced and instead, zinc oxide face compresses and bandages for limbs may be applied. Studies of alternative non-steroid treatments such as homeopathic remedies and acupuncture in the treatment of eczema have not demonstrated adequate clinical benefit and this needs to be communicated to the patient who is likely to have lost some faith in conventional medical therapies.
For many patients, eczema is a chronic disease thus it is worthwhile signposting them to eczema support groups such as the National Eczema Society. If available, dermatology day centres/dressing clinics run by experienced dermatology nurses are a useful means of rebuilding confidence and providing support with topical treatment, observing topical application techniques, knowledge of finger-tip unit and often reveals whether a patient is under or over treating. Patients can trial a range of topical treatments and a tailored regime can be formulated which is likely to increase adherence.
Dermatology life quality index (DLQI), (patient health questionnaire-9) PHQ9 and (general anxiety disease) GAD scores are some indicator of the level of distress associated with eczema and highlights those who are more likely to need psychological support. It is important that patients are given the opportunity to discuss psychosocial stresses which may mitigate the benefits of a home topical treatment plan. Psychologists with experience in supporting patients with skin disease can explore attitudes to treatment, including concerns about steroid addiction and home stresses which may perpetuate eczema.
A cognitive behavioural therapeutic approach is often very helpful in achieving a shared treatment plan – a collaboration between the clinical team and the patient. This multidisciplinary approach which is patient-centred has been recognised as increasing adherence and ultimately improving outcomes in more severe, treatment resistant chronic skin diseases including eczema which inevitably have significant psychosocial secondary effects.
It is not always possible or necessary to access a psychologist – by being curious about our patient’s perspective, spending a little more time with our patients and eliciting their concerns and listening attentively each time they return for a treatment review, we maximise the potential for success with a treatment regime which is tailored to their lives and therefore much more likely to be effective.