Clinical Topic A-Z Clinical Speciality

Corticosteroids - topical (skin), nose, and eyes

Corticosteroids - topical (skin), nose, and eyes
D000287Administration, Topical
D000305Adrenal Cortex Hormones
Drugs and devices
2010-08-23Last revised in August 2010

Corticosteroids - topical (skin), nose, and eyes - Summary

Corticosteroids are synthetic analogues of the natural hormones that are produced by the adrenal cortex.

Local corticosteroids are predominantly glucocorticoids. They have four main effects:

Anti-inflammatory effects.

Immunosuppressive effects.

Anti-proliferative (anti-mitotic) effects.

Vasoconstrictive effects.

Topical corticosteroids exert these effects on the skin:

Eczema — the anti-inflammatory effects are important.

Contact dermatitis — the immunosuppressive effects are important.

Psoriasis — is characterized by rapid cell turnover, and the anti-mitotic effects are of benefit.

Intranasal corticosteroids exert these effects on the nasal mucosa, where they relieve or prevent the symptoms associated with allergic rhinitis (nasal congestion, itching, runny nose, and sneezing). They can also be used in the short-term to shrink nasal polyps.

Corticosteroid eye preparations control inflammation of the eye due to allergy, trauma or infection.

Topical corticosteroids:

Can be used to treat a number of conditions; the length of treatment depends on the diagnosis. Generally, potent topical corticosteroids should not be used regularly for more than 7 days. If treatment is indicated for longer, specialist advice should be considered.

Should be withdrawn gradually if treatment is long term. Abrupt withdrawal can cause a relapse or rebound of the condition being treated (for example psoriasis or eczema). Reddening of the skin (rebound erythroderma) has also been (rarely) reported.

Should be avoided in people with bacterial, fungal, or viral skin lesions; rosacea; perioral dermatitis; acne; or ulceration.

Should not be used indiscriminately for itching.

Local adverse effects of topical corticosteroids occur mostly occur on the face, in skin folds, and in areas that are treated over the long term. Adverse effects include:

Transient burning or stinging.

Thinning of the skin.

Permanent stretch marks.

Acne (or worsening of existing acne) or rosacea.

Intranasal corticosteroids:

Are more likely to cause systemic adverse effects when delivered by intranasal drops compared with sprays.

Should not be used in the presence of untreated nasal infections; after nasal surgery before healing has occurred, unless on specialist advice; or if there is pulmonary tuberculosis.

The intranasal corticosteroids that are available in the UK are equally effective.

Approximately 10% of people develop local adverse effects from intranasal corticosteroids (including dryness, irritation, and nosebleed — this may require stopping treatment for a while). Reddening of the skin, rash, itching, headache, and disturbance of smell and taste may also occur. Nasal ulceration has been reported.

Corticosteroid eye preparations:

Should always be initiated in secondary care. Treatment may be continued and monitored in primary care, following a management plan agreed with the specialist. This is because an undiagnosed red eye may be due to herpes simplex virus, or bacterial, fungal, or amoebic infections and the use of corticosteroid eye preparations may worsen the condition. Also, about 30% of people receiving corticosteroid eye preparations develop increased intraocular pressure, leading to steroid-induced glaucoma.

May cause steroid-induced cataract if use is prolonged.

Should not be used with soft contact lenses — lenses should be removed before instillation of drops, and not worn during the period of treatment.

Have I got the right topic?

0months3060monthsBoth

This CKS topic covers the management of people receiving topical corticosteroids, intranasal corticosteroids and corticosteroid eye preparations in primary care.

This CKS topic does not cover the management of the specific condition for which the person is receiving topical corticosteroids, intranasal corticosteroids and corticosteroid eye preparations. It also does not include information on drug doses.

For information on rectal corticosteroids, see the CKS topics on Crohn's disease and Ulcerative colitis.

For information on inhaled corticosteroids, see the CKS topics on Corticosteroids - inhaled, Asthma, and Chronic obstructive pulmonary disease.

The following CKS topics include information on the use of topical and intranasal corticosteroids:

Topical corticosteroids

Aphthous ulcer

Dermatitis - contact

Eczema - atopic

Insect bites and stings

Nappy rash

Psoriasis

Scabies

Seborrhoeic dermatitis

Urticaria

Intranasal corticosteroids

Allergic rhinitis

Intraocular corticosteroids should always be initiated in secondary care. Dosage information will therefore be provided by the specialist.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.

CKS gratefully acknowledges the contribution of the British Association of Dermatologists in the development of this topic.

How up-to-date is this topic?

How up-to-date is this topic?

Changes

Last revised in August 2010

January 2011— changed the title of the topic to Corticosteroids - topical (skin), nose, and eyes. The initial title corticosteroids - topical (skin, nose, and eyes) was inappropriate because for the purpose for this topic, topical refers to corticosteroid preparations used on the skin. Also changed the term 'intraocular corticosteroids' to corticosteroid eye preparations through out the entire document, as it is a more accurate terminology.

September 2010 — minor update. The Medicines and Healthcare products Regulatory Agency (MHRA) has reminded prescribers that psychological and behavioural side effects may occur in association with the use of intranasal corticosteroids [MHRA, 2010]. Issued in September 2010.

April to August 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 March 2010.

HTAs (Health Technology Assessments)

No new HTAs since 1 March 2010.

Economic appraisals

No new economic appraisals relevant to England since 1 March 2010.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 March 2010.

Primary evidence

No new randomized controlled trials published in the major journals since 1 March 2010.

Observational studies published since the last revision of this topic:

Chi, C.C., Wang, S.H., Mayon-White, R. and Wojnarowska, F. (2013) Pregnancy outcomes after maternal exposure to topical corticosteroids: a UK population-based cohort study. JAMA Dermatology 149(11), 1274-1280. [Abstract]

Johannesdottir, S.A., Horvath-Puho, E., Dekkers, O.M., et al. (2013) Use of glucocorticoids and risk of venous thromboembolism. A nationwide population-base case-control study. JAMA Internal Medicine 173(9), 743-752. [Abstract]

New policies

No new national policies or guidelines since 1 March 2010.

New safety alerts

The Medicines and Healthcare products Regulatory Agency (MHRA) has reminded prescribers that psychological and behavioural side effects may occur in association with the use of intranasal and inhaled corticosteroids.

Reference: MHRA (2010) Inhaled and intranasal corticosteroids: risk of psychological and behavioural side effects. Drug Safety Update 4(2), A4. [Free Full-text]

Changes in product availability

No changes in product availability since 1 March 2010.

Goals and outcome measures

Goals

To support primary health care professionals to ensure that people receiving topical corticosteroids, intranasal corticosteroids, and corticosteroid eye preparations in primary care are properly managed and monitored

Background information

Definition

What are corticosteroids?

Corticosteroids are synthetic analogues of the natural hormones that are produced by the adrenal cortex.

Like the natural hormones, synthetic corticosteroids can have glucocorticoid and/or mineralocorticoid properties.

The glucocorticoid properties are anti-inflammatory, immunosuppressive, anti-proliferative, and vasoconstrictive. The glucocorticoid properties also support a variety of cardiovascular and metabolic functions, and help the body adjust to physical stress.

The mineralocorticoid properties include the regulation of electrolytes and water balance, by promoting sodium retention by the kidneys.

Different corticosteroids have varying ratios of mineralocorticoid to glucocorticoid properties. The ratio determines the corticosteroid's efficacy and therapeutic use.

Corticosteroids can be administered systemically (orally and parenterally) or locally (topically to the skin, nose and eyes; by inhalation; rectally and by intra-articular injection).

[Walker and Edwards, 1999; Rang et al, 2007]

Action of local corticosteroids

How do local corticosteroids work?

Local corticosteroids are predominantly glucocorticoids. They have four main effects [Coulson, 1996; Menter et al, 2009]:

Anti-inflammatory effects — they inhibit inflammation by blocking the action of inflammatory mediators (such as prostaglandins).

Immunosuppressive effects — they suppress delayed hypersensitivity reactions (by directly affecting T-lymphocytes).

Anti-proliferative (anti-mitotic) effects — they inhibit epidermal DNA synthesis and epidermal cell turnover.

Vasoconstrictive effects — they inhibit the action of histamine and other vasoconstrictive mediators, and also directly affect vascular endothelial cells. The most potent topical steroids are also the most vasoconstrictive.

Topical corticosteroids exert these effects on the skin to treat various inflammatory skin conditions, such as:

Eczema — the anti-inflammatory effects of the corticosteroid are important.

Contact dermatitis — the immunosuppressive effects of the corticosteroid are important.

Psoriasis — is characterized by rapid cell turnover, and the anti-mitotic effects of corticosteroids are of benefit.

Intranasal corticosteroids exert these effects on the nasal mucosa, where they relieve or prevent the symptoms associated with allergic rhinitis (nasal congestion, itching, runny nose, and sneezing).

They can also be used (as short courses of treatment) to shrink nasal polyps.

Corticosteroid eye preparations exert these effects in the eyes, where they control inflammation due to allergy, trauma or infection.

Availability

Which local (skin, nose and eyes) corticosteroids are available in the UK?

Topical

Topical

Topical corticosteroids are available in different formulations and potencies. Some are also available as compound preparations containing substances such as antibacterials, antifungals, and salicylic acid.

The benefit of including antibacterials or antifungals with a topical corticosteroid is uncertain. However, this does not mean that they do not work.

When prescribing combination products, select the antimicrobial drug according to the sensitivity of the infecting organism. The preparation should typically be used twice daily for a maximum of 7 days. Longer use increases the risk of resistance and sensitization.

Small packs of hydrocortisone and clobetasone butyrate are available over-the-counter for short-term use in skin conditions such as dermatitis and insect bites:

Hydrocortisone — creams and ointments containing hydrocortisone 1% (alone or combined with other ingredients) are available over-the-counter for short-term use (maximum 7 days).

Clobetasone butyrate — clobetasone 0.05% (15 g tube) is available over-the-counter for short-term (7 days) symptomatic treatment of eczema and dermatitis (but not seborrhoeic dermatitis). It is licenced to be used by adults and children 12 years of age and older.

[Birnie et al, 2008; BNF 59, 2010]

Intranasal

Intranasal

Intranasal corticosteroids are available as sprays or drops.

The intranasal corticosteroids that are available in the UK include:

Beclometasone dipropionate (spray).

Betamethasone sodium phosphate (drops).

Budesonide (spray).

Flunisolide aqueous (spray).

Fluticasone propionate aqueous (spray and drops).

Mometasone furoate (spray).

Triamcinolone acetonide (aqueous spray).

Small packs of some intranasal corticosteroids (beclometasone, budesonide, fluticasone, and triamcinolone) are available over-the-counter for the prevention and treatment of seasonal allergic rhinitis in adults 18 years of age and older.

[BNF 59, 2010]

Eye preparations

Eye preparations

Corticosteroid eye preparations are available as drops, ointment, ophthalmic suspensions, and Minims® (preservative-free, single-use application packs). Some are also available as compound preparations, containing antibacterials.

The corticosteroid eye preparations available in the UK include:

Betamethasone (drops and ointment).

Dexamethasone (drops and Minims®).

Fluorometholone (ophthalmic suspension).

Hydrocortisone acetate (drops and ointment).

Loteprednol etabonate (ophthalmic suspension).

Prednisolone (drops and Minims®).

Rimexolone (drops).

[BNF 59, 2010]

Management

Management

Scenario: Topical treatment : covers the management of people receiving topical (skin) corticosteroids in primary care.

Scenario: Intranasal treatment : briefly covers the management of people receiving intranasal corticosteroids in primary care.

Scenario: Eye treatment : briefly covers the management of people receiving corticosteroid eye preparations. Although corticosteroid eye preparations are initiated in secondary care, treatment may be continued and monitored by a general practitioner.

Scenario: Topical treatment

Scenario: Topical treatment

0months3060monthsBoth

Initiation

What should I consider when initiating topical corticosteroids?

Topical corticosteroids are effective and have few adverse effects if they are used appropriately.

The choice of topical corticosteroid depends on the condition being treated (and its stage), the area of the body that is affected, and the age of the person.

Condition being treated and its stage — mild forms of dermatitis may only require a mild topical corticosteroid whereas psoriasis may require a more potent topical corticosteroid.

Prescribe the least potent steroid that relieves the symptoms, and an appropriate quantity.

If the treatment is for a flare up of disease activity, taper the treatment by using a less potent steroid once the flare up is under control.

The person's age — children and elderly people are more susceptible to the adverse effects of topical corticosteroids because they have a thinner epidermis. Elderly people also have decreased dermal collagen (due to age and sun damage).

Area of body being treated

Areas where the skin is thin or flexural (such as the face, scrotum, groin, axillae, and submammary area) usually require a weak or moderately-potent corticosteroid.

Areas where the skin is thick, due to either site (palms of the hands and soles of the feet) or from constant scratching (lichenification), usually require more potent preparations.

Consider prescribing an emollient with the topical corticosteroid (to moisturize the skin).

Basis for recommendation

Basis for recommendation

Theses recommendations are based on published expert opinion [Coulson, 1996; Menter et al, 2009] and the British National Formulary [BNF 59, 2010].

Length of treatment

How long can I prescribe topical corticosteroids for?

The length of treatment depends on the condition being treated.

Generally, potent topical corticosteroids should not be used regularly for more than 7 days. If treatment is indicated for longer than 7 days, consider seeking specialist advice.

Supervise repeat prescriptions for topical corticosteroids and review the person regularly (every 6–12 months, depending on the individual, their condition, and the potency of the topical corticosteroid).

If the symptoms do not improve after 3–7 days, reassess the condition and consider other potential causes:

Infection — such as impetigo, herpes simplex, or tinea corporis, which can be worsened by topical corticosteroids. Investigate, and treat with the appropriate anti-infective drug.

Hypersensitivity reaction — consider switching to a corticosteroid with a different active ingredient or refer the person to a dermatologist if there is any doubt as to the reason for the reaction.

Non-adherence — this could be due to concerns about the safety of steroids. Reassure the person that adverse effects are rare when topical steroids are applied thinly and for a short period.

Tolerance — consider switching to another topical corticosteroid of the same potency.

Basis for recommendation

Basis for recommendation

These recommendations are based on a drug reference database [Sweetman, 2009], and published expert opinion [Dermatology UK, 2007; Menter et al, 2009].

Contact sensitivity can develop, both to the preservatives and to the steroid molecule; it may be difficult to distinguish this from worsening of the condition being treated [MeReC, 1999].

The recommendation to supervise repeat prescriptions for topical corticosteroids and review the person regularly, is based on what CKS considers to be good clinical practice.

Potency

What potency of topical corticosteroids should I prescribe?

Topical corticosteroids are available in four potencies: mildly potent, moderately potent, potent, and very potent (see Table 1 for more details). Prescribe the least potent preparation which is effective, and avoid dilution if possible.

The potency of topical corticosteroids is determined by the amount of vasoconstriction they produce. However, potency can be affected by several factors.

Table 1 . Topical corticosteroids listed in the British National Formulary.
Potency class Non-proprietary names and strengths Proprietary names Formulations
Mild Hydrocortisone 0.1%, 0.5%, 1.0%, 2.5% Generic hydrocortisone, Dioderm®, Efcortelan®, Mildison® Creams and ointments
Moderate Alclometasone dipropionate 0.05% Modrasone® Cream and ointment
Betamethasone valerate 0.025% Betnovate-RD® Cream and ointment
Clobetasone butyrate 0.05% Eumovate® Cream and ointment
Fluocinolone acetonide 0.001% Synalar 1 in 4 dilution® Cream and ointment
Fluocortolone 0.25% Ultralanum Plain® Cream and ointment
Fludroxycortide 0.0125% Haelan® Cream and ointment
Potent Betamethasone dipropionate 0.05% Diprosone® Cream, ointment, and lotion
Betamethasone valerate 0.1% Generic betamethasone valerate, Betnovate® Cream, ointment, lotion, and scalp application. Foam (0.12%)
Diflucortolone valerate 0.1% Nerisone® Cream, ointment, and oily cream
Fluocinolone acetonide 0.025% Synalar® Cream, ointment, and gel
Fluocinonide 0.05% Metosyn® Cream and ointment
Fluticasone propionate 0.05% Cutivate® Cream and ointment
Hydrocortisone butyrate 0.1% Locoid® Cream, ointment, lipocream, and scalp application
Mometasone furoate 0.1% Elocon® Cream, ointment, and scalp application
Very potent Clobetasol propionate 0.1% Dermovate®, Clarelux® Cream, ointment, and scalp application
Diflucortolone valerate 0.3% Nerisone Forte® Ointment and oily cream
Data from: [BNF 59, 2010]

Factors affecting potency

Factors that affect the potency of topical corticosteroids

The potency of a topical corticosteroid can be affected by:

The degree to which it inhibits inflammation.

The formulation — ointments are more potent than creams.

The presence of other ingredients (for example urea or salicylic acid), which may increase the potency of the topical corticosteroid.

The salt of the steroid (for example hydrocortisone is a mild steroid, but hydrocortisone butyrate is a potent steroid).

Using it under occlusion, which increases the risk of systemic absorption and adverse effects.

Fluorination — fluorinated corticosteroids (such as Dermovate®, Haelan®, Metosyn®, and Cutivate®) have been modified to increase their potency; this increases the risk of adverse effects.

Basis for recommendation

Basis for recommendation

Information regarding the potency of topical corticosteroids is taken from the British National Formulary [BNF 59, 2010].

The factors that determine the potency of topical corticosteroids are based on published expert opinion [MeReC, 1998], the British National Formulary [BNF 59, 2010], and a drug reference database [Sweetman, 2009].

Using topical corticosteroids under occlusion increases the risk of systemic absorption and adverse effects [Sweetman, 2009].

Formulations

What formulation of topical corticosteroids should I prescribe?

Topical corticosteroids are available in several formulations, including creams, ointments, lotions, gels, tapes, mousses, and solutions.

The choice of formulation depends on the condition being treated, its severity and location, and the person's preference.

Solutions

Solutions are low viscosity, alcohol- or water-based liquids.

They are easy to apply and are non-greasy.

They are very drying if alcohol is the base, and can sting sore skin.

Lotions

Lotions are similar to solutions, but thicker.

They are useful for treating large or hairy areas, and for treating exudative lesions.

Creams

Creams are thicker than lotions and are suitable for moist or weepy lesions.

They are moisturizing without being greasy. Many people prefer them, especially for use on the face and palms of the hands.

Ointments

Ointments are preferred for dry, lichenified, or scaly conditions.

They have a more prolonged emollient effect and tend to increase the potency of the corticosteroid.

They are less likely to cause irritation as they are usually preservative-free.

Gels and mousses

Gels are thicker than solutions, and can be drying.

Mousses are stable, non-greasy foams.

Gels and mousses can be useful for scalp conditions.

Tapes/bandages

Occlusive polythene or hydrocolloid dressings increase the absorption of the steroid, and increase the risk of adverse effects.

They should only be used under supervision for a short period of time, and for areas of very thick skin (such as the palms of the hands and soles of the feet).

Topical corticosteroids are also available as compound preparations, which contain other substances such as:

Antibacterials and antifungals — for infected skin.

Salicylic acid, calcipotriol, or coal tar — for psoriasis and other dry skin conditions.

Some of these substances (for example urea and salicylic acid) may increase the penetration of the corticosteroid.

Basis for recommendation

Basis for recommendation

These recommendations are based on published expert opinion [Coulson, 1996; MeReC, 1999; Menter et al, 2009].

The choice of formulation depends on the condition being treated, its severity and location, and the person's preference [Coulson, 1996; Menter et al, 2009].

Ointments are preferred for dry, lichenified, or scaly conditions. They have a more prolonged emollient effect and tend to increase the potency of the corticosteroid. They are also less likely to cause irritation as they are usually preservative-free [BNF 59, 2010].

Tapes — occlusive polythene or hydrocolloid dressings increase the absorption of the steroid, and increase the risk of adverse effects. They should only be used under supervision for a short period of time, and for areas of very thick skin [BNF 59, 2010].

The description of the formulations is from a textbook [Warner and Camisa, 2001; Wolverton, 2001].

Application

How should topical corticosteroids be applied?

A thin layer of topical corticosteroid should be applied once or twice daily, adjusting the potency to control symptoms. For many conditions, once-daily application is usually sufficient.

The corticosteroid should typically be used in bursts of 3–7 days in order to achieve control. Once a clinical response is seen, withdraw gradually. Some improvement may be seen within 2–3 days.

If an emollient is being used, instruct the person to apply this first and then wait 30 minutes before applying the topical corticosteroid (that is, after the emollient has been fully absorbed).

Most products are supplied with an information leaflet specifying the number of finger-tip units (FTUs) needed to treat specific body areas.

One FTU is the length of cream or ointment expelled from the tube equivalent to the distance from the tip of the adult index finger to the first crease. One FTU is about 500 mg and is sufficient to treat a skin area about twice that of the flat of the hand with the fingers together.

See Finger tip units (FTUs) for adults and Finger tip units (FTUs) for children for the approximate amount of topical corticosteroid that should be applied to different areas of the body.

Finger tip units (FTUs) for children

Finger tip units (FTUs) for children

The finger-tip unit (FTU) is measured on an adult index finger.

The approximate amount of topical corticosteroid that should be applied to children, for each area of the body, is listed in Table 1.

Table 1 . Amount of topical preparation (in FTUs) for different areas of a child's body.
Age of child Entire face and neck Entire arm and hand Entire leg and foot Entire front of chest and abdomen Entire back including buttocks
3–6 months 1 1 1.5 1 1.5
1–2 years 1.5 1.5 2 2 3
3–5 years 1.5 2 3 3 3.5
6–10 years 2 2.5 4.5 3.5 5
Data from: [Long et al, 1998; MeReC, 1999]

Finger tip units (FTUs) for adults

Finger tip units (FTUs) for adults

The approximate amount of topical corticosteroid that should be applied to adults, for each area of the body, is listed in Table 1.

Table 1 . Amount of topical preparation (in finger-tip units [FTUs]) for different areas of an adult's body.
Body area Number of FTUs
Scalp 3
Face and neck 2.5
One hand (front and back including fingers) 1
One arm (including entire hand) 4
Elbows (large plaque) 1
Both soles (of feet) 1.5
One foot (dorsum and sole) including toes 1.5
One leg (including entire foot) 8
Buttocks 4
Knees (large plaque) 1
Trunk (front) 8
Trunk (back) 8
Genitalia 0.5
Data from: [Menter et al, 2009]

Basis for recommendation

Basis for recommendation

Frequency of application

The frequency of application of topical corticosteroids has been the subject of a National Institute for Health and Care Excellence (NICE) Technology Appraisal that identified 10 randomized controlled trials (RCTs). The evidence suggested that, overall, there was little difference in effectiveness between once-daily and more frequent application of topical corticosteroids, although a difference could not be ruled out [NICE, 2004].

Taking into account cost-effectiveness information, NICE recommends that topical corticosteroids should be prescribed 'for application only once or twice daily'.

CKS recommends that, on a practical basis, most people should use topical corticosteroids once daily at first, and increase to twice daily only if the condition does not respond adequately [Williams, 2007].

A total of 10 RCTs compared once daily application with more frequent use of topical corticosteroids within the same potency group, for eczema. None of the studies found clear evidence that application more than once a day produced better overall clinical outcomes.

The recommendation to use topical corticosteroids in bursts of 3–7 days is based on published expert opinion [MeReC, 1999; Williams, 2005].

Combining topical corticosteroids and emollients

CKS found no controlled studies investigating the efficacy of combining topical corticosteroids and emollients. CKS recommends that when both treatments are being used, the emollient should be used first, followed by the topical corticosteroid, preferably after waiting for 30 minutes.

NICE states that 'a short interval (several minutes) should be left between application of a topical corticosteroid and an emollient, where practicable' [National Collaborating Centre for Women's and Children's Health, 2007].

The clinical guideline Best practice in emollient therapy published by the International Skin Care Nursing Group, states that emollients should be allowed to absorb before topical corticosteroids are applied (the skin should be moist or slightly tacky, but not slippery) [Dermatology UK, 2007]. This is because:

Application of corticosteroid immediately on top of, or before, an emollient may dilute the product and transfer corticosteroid to areas that do not require treatment.

The British National Formulary advises that mixing topical preparations on the skin should be avoided where possible; several minutes should elapse between application of different preparations [BNF 59, 2010].

Some experts recommend that the corticosteroid should be applied first. This is also a reasonable strategy, provided the emollient is not applied too quickly (particularly on top of corticosteroid ointment), diluting the corticosteroid. Waiting for 1 hour is suggested by some experts.

Finger-tip units (FTUs) and children

This recommendation is based on published expert opinion [Long et al, 1998; MeReC, 1999].

Quantity to prescribe

How much topical corticosteroid should I prescribe?

It is important that the appropriate quantity of topical corticosteroid is prescribed (to avoid undertreatment).

For suitable quantities of topical corticosteroid creams and ointments to prescribe, assuming the person is applying treatment twice a day for 2 weeks, see Table 1.

For the weekly dose of topical corticosteroids unlikely to cause systemic adverse effects in adults, see Table 2.

Table 1 . Suitable quantities of corticosteroids to prescribe (application twice a day for 2 weeks).
Area of the body Suitable quantity to prescribe
Face and neck 15–30 g
Both hands 15–30 g
Scalp 15–30 g
Both arms 30–60 g
Both legs 100 g
Trunk 100 g
Groin and genitalia 15–30 g
Data from: [BNF 59, 2010]
Table 2 . Weekly dose of topical corticosteroids unlikely to cause systemic adverse effects in adults.
Treatment period Moderately potent (g) Potent (g) Very potent (g)
< 2 months 100 50 30
2–6 months 50 30 15
6–12 months 25 15 7.5
Data from: [Coulson, 1996]

Basis for recommendation

Basis for recommendation

These recommendations are based on published expert opinion [Coulson, 1996] and the British National Formulary [BNF 59, 2010].

Some CKS experts reviewers consider undertreatment to be an 'adverse effect' of topical corticosteroids.

Undertreatment is a significant problem in primary care. It is caused by several factors, including under-prescribing and failure to use a sufficient quantity [Beattie and Lewis-Jones, 2003].

Withdrawal

How do I withdraw or stop topical corticosteroid treatment?

Withdraw long-term topical corticosteroid treatment gradually. Abrupt withdrawal can cause a relapse or rebound of the condition being treated (for example psoriasis or eczema). Reddening of the skin (rebound erythroderma) has also been (rarely) reported.

Once a clinical response has been seen, taper the dose of corticosteroid. The following options can be considered:

Step down to a lower-potency corticosteroid.

Use a lower-potency corticosteroid with other topical treatments (such as vitamin D preparation or coal tar in psoriasis).

Use a lower-potency corticosteroid intermittently.

Basis for recommendation

Basis for recommendation

This recommendation is based on a drug reference database [Sweetman, 2009].

Flares of eczema may occur if steroids are stopped abruptly. Topical steroids should be withdrawn gradually, decreasing the potency in a stepwise manner [MeReC, 1999].

Some CKS experts reviewers consider gradual withdrawal to be unnecessary, and may adversely influence compliance (especially when treating children).

Options for withdrawal of topical corticosteroids are based on published expert opinion [Coulson, 1996; MeReC, 1999; Menter and Griffiths, 2007; van de Kerkhof et al, 2008; Menter et al, 2009].

Contraindications and cautions

What contraindications and cautions are associated with topical corticosteroids?

Contraindications

Avoid topical corticosteroids in people with:

Bacterial, fungal, or viral skin lesions.

Rosacea.

Perioral dermatitis.

Acne.

Ulcerations.

Topical corticosteroids should not be used indiscriminately for itching.

Cautions

Potent topical corticosteroids should generally not be used on sensitive areas (including the face, axillae, and genitals).

Use topical corticosteroids with caution in the periocular area.

Basis for recommendation

Basis for recommendation

Contraindications

These recommendations are based on published expert opinion [MeReC, 1999] and a drug reference database [Sweetman, 2009].

Topical corticosteroids should be avoided on infected skin (unless the infection is being treated) [MeReC, 1999].

Cautions

These recommendations are based on published expert opinion [Coulson, 1996; MeReC, 1999] and a drug reference database [Sweetman, 2009].

The SIGN guideline on Management of atopic eczema in primary care recommends that topical corticosteroids should be used with caution in the periocular area [SIGN, 2011].

Pregnancy and breastfeeding

Can I prescribe topical corticosteroids to a woman who is pregnant, planning a pregnancy or breastfeeding?

Pregnancy

Mildly potent, moderately potent, and potent topical corticosteroids, if used correctly, are considered suitable for use during pregnancy.

Very potent topical corticosteroids may be associated with low birthweight. If a very potent corticosteroid is being considered for use during pregnancy, seek specialist advice.

Breastfeeding

Mildly potent, moderately potent, and potent topical corticosteroids are considered suitable for use during breastfeeding.

The risk of systemic absorption can be minimized by using the weakest potency possible, for the shortest period of time.

If the topical corticosteroid is applied to the breasts, it should be washed off before breastfeeding to prevent the infant ingesting it.

Basis for recommendation

Basis for recommendation

Pregnancy

These recommendations are based on published expert opinion [Schaefer et al, 2007; Weatherhead et al, 2007].

A Cochrane systematic review identified two cohort studies and five case-control studies (with 659,675 participants) of women who were exposed to topical corticosteroids during pregnancy [Chi et al, 2009].

These studies had several methodological weaknesses, which made the results difficult to interpret. The authors of the review considered the studies to be of low or very low quality.

From these data, no association was found between use of topical corticosteroids during pregnancy and congenital abnormality, pre-term delivery, or stillbirth.

Some evidence suggested that very potent topical corticosteroids might be associated with low birthweight.

Breastfeeding

Potent corticosteroids are considered suitable for use during breastfeeding [WHO, 2002].

Adverse effects

What are the adverse effects of topical corticosteroids?

When used correctly, topical corticosteroids rarely cause serious adverse effects.

The likelihood of adverse effects is directly related to:

Duration of treatment — long-term treatment is likely to result in systemic absorption.

Area of the skin being treated — treating large areas of skin increases the risk of absorption.

Condition of the skin — absorption is greatest in thin, inflamed skin.

Potency of the topical corticosteroid — the greater the potency, the greater the risk of absorption.

Occlusion — use of topical corticosteroids under occlusion increases the risk of systemic absorption.

Age — children and elderly people are more susceptible to the adverse effects of topical corticosteroids because they have a thinner epidermis. Elderly people also have reduced dermal collagen (due to age and sun damage).

Local adverse effects are more common. They mostly occur on the face, in skin folds, and in areas that are treated over the long term. Local adverse effects include:

Transient burning or stinging — this is common, especially in the first 2 days of application on untreated, inflamed skin. It does not usually warrant a change of treatment, as it improves as the skin responds to treatment.

Worsening and spreading of untreated infection.

Thinning of the skin — the skin improves over a period after stopping treatment.

Permanent stretch marks.

Allergic contact dermatitis — due to the corticosteroid or the excipients.

Acne (or worsening of existing acne) or rosacea.

Mild depigmentation — usually reversible.

Excessive hair growth at the site of application (hypertrichosis).

Systemic adverse effects are rare, but may include:

Adrenal suppression.

Cushing's syndrome.

Growth retardation in children.

Basis for recommendation

Basis for recommendation

The likelihood of adverse effects is based on published expert opinion [Coulson, 1996] and the British National Formulary [BNF 59, 2010].

Children (especially babies) are more susceptible to the adverse effects of topical corticosteroids as they tend to have a thinner epidermis [Coulson, 1996]. However, these concerns should not lead to undertreatment [BNF 59, 2010].

Local adverse effects are based on the British National Formulary [BNF 59, 2010] and a drug reference database [Sweetman, 2009].

Serious adverse effects are rare, and this is reflected in the available safety data. For example, the Summary of Product Characteristics for Betnovate® (betamethasone valerate) states that both features of Cushing's syndrome and skin disorders (such as thinning, striae, and dilatation) are 'very rare', meaning they affect less than one in 10,000 people (based on case reports rather than controlled trials) [ABPI Medicines Compendium, 2007].

Minimizing adverse effects

How do I minimize the risks of adverse effects in people using topical corticosteroids?

To minimize the adverse effects of topical corticosteroids:

Prescribe the least potent formulation which is fully effective (advise the person to apply it thinly to affected areas, no more than twice daily).

Consider prescribing an appropriate quantity of an emollient for use alongside the topical corticosteroid (for moisturizing purposes).

Avoid prescribing potent corticosteroids for use on the face.

Unless under specialist supervision, the use of potent (such as betamethasone valerate 0.1%) and very potent (such as clobetasol propionate 0.1%) topical corticosteroids, should be limited to:

Use for up to 2 weeks, and

No more than 50 g each week.

Once–daily application is usually sufficient — maximum of twice daily.

For more information, see the section on Availablity potency and choice in the CKS topic on Psoriasis.

Avoid using occlusive dressings with topical corticosteroids (especially on large areas of the body).

If a topical corticosteroid is needed for maintenance therapy, consider incorporating regular periods when they are withdrawn (for as long as possible) and emollients are used on their own.

If the person is using large amounts of topical corticosteroid regularly, monitor them for signs of systemic adverse effects (such as adrenal suppression) and local adverse effects (such as areas of thin skin or striae).

Monitor the height of children who are using large amounts of topical corticosteroid.

Basis for recommendation

Basis for recommendation

The recommendations for minimizing adverse effects are based on published expert opinion [Coulson, 1996], a manufacturer's Summary of Product Characteristics [ABPI Medicines Compendium, 2007], the British National Formulary [BNF 59, 2010], and a drug reference database [Sweetman, 2009].

Topical corticosteroids should not be applied with an occlusive dressing to large areas of the body, as there is a high risk of systemic absorption and adverse effects [Sweetman, 2009].

Occlusive dressings substantially increase the systemic absorption of topical corticosteroids [ABPI Medicines Compendium, 2007].

Information and advice

What information and advice should I give to a person receiving topical corticosteroids?

Explain about the potency of the topical steroid that has been prescribed, and if possible provide a written treatment plan, outlining:

How much to apply — explain finger-tip units (FTUs), and advise the person to apply the topical corticosteroid thinly to the affected area. If the person finds it difficult to understand FTUs, explain that they should ensure that the skin is slightly shiny after the cream is applied.

How long to apply— advise the person not to use topical corticosteroids for longer than prescribed.

How often to apply — once daily (or twice daily if absolutely necessary).

Where to apply — topical corticosteroids should not be applied to the face and other sensitive areas, except when advised.

How to apply — topical corticosteroids should not be mixed with other creams, except when advised. Advise the person to:

Use an emollient first, then wait at least 30 minutes before applying the topical corticosteroid (only after the emollient has been fully absorbed).

Avoid vigorously rubbing the topical corticosteroid into the skin. The corticosteroid should be applied gently in the direction of the hair growth to prevent occlusion folliculitis.

Reassure the person that, when used correctly, topical corticosteroids rarely cause serious adverse effects. However, advise that they should seek help if they notice any adverse effects (such as skin thinning, stretch marks, or acne).

Advise the person to carry a steroid treatment card if they are receiving long-term treatment (several weeks) with a potent or very potent topical corticosteroid.

Basis for recommendation

Basis for recommendation

These recommendations are based on published expert opinion [Coulson, 1996; MeReC, 1999] and the British National Formulary [BNF 59, 2010].

The recommendation to explain about the potency of the prescribed topical corticosteroid and provide a skin treatment plan is based on published opinion, and what CKS considers to be good practice.

A questionnaire-based study was conducted to determine the level of use, and knowledge, of commonly-prescribed topical corticosteroids among parents or carers of 100 children attending paediatric outpatient clinics [Beattie and Lewis-Jones, 2003].

44% of parents/carers graded hydrocortisone 1% as potent.

42% did not grade betamethasone valerate 0.1% as potent.

29% graded clobetasol butyrate 0.05% as potent, and 12% graded it as weak.

Poor adherence is a major cause of treatment failure in atopic dermatitis. The reasons for this include fear of adverse effects, failure to renew prescriptions on time, and lack of time. Most important however, is lack of knowledge about the treatment [Beattie and Lewis-Jones, 2003].

The recommendation to issue a steroid treatment card if the person is receiving long-term treatment (several weeks) with a potent or very potent topical corticosteroid, is based on what CKS considers to be good practice.

A guideline published by the Medicines and Healthcare products Regulatory Agency (MHRA) advises that high-risk people should be provided with a steroid card, at the discretion of the prescriber or pharmacist [CHM, 2006].

Most topical corticosteroids may, under certain circumstances, be absorbed in sufficient amounts to cause systemic adverse effects [Sweetman, 2009].

Scenario: Intranasal treatment

Scenario: Intranasal treatment

0months3060monthsBoth

Initiation

What should I consider when initiating intranasal corticosteroids?

Intranasal corticosteroids are available as drops and sprays. The risk of systemic adverse effects is considered more likely with drops (as they are more likely to be administered incorrectly).

The intranasal corticosteroids that are available in the UK are equally effective.

However, for children, consider prescribing a preparation containing fluticasone propionate, mometasone, budesonide, or triamcinolone.

Basis for recommendation

Basis for recommendation

These recommendations are based on published expert opinion [Schenkel et al, 2000; Yawn, 2006; London New Drugs Group, 2008], and the British National Formulary [BNF 59, 2010].

The BNF states that the risk of systemic adverse effects may be greater with nasal drops than with nasal sprays; drops are administered incorrectly more often than sprays [BNF 59, 2010].

Choice of intranasal corticosteroid for children

Experts recommend budesonide, fluticasone, and mometasone for children [Schenkel et al, 2000; Yawn, 2006]. The BNF also recommend these intranasal corticosteroids in children, as well as triamcinolone.

Intranasal beclometasone affects growth in children [BNF 59, 2010].

CKS found several small studies comparing intranasal corticosteroids with placebo in children with allergic rhinitis.

 A year-long randomized controlled trial (RCT), in 100 children 6–9 years of age, compared intranasal beclometasone (168 micrograms twice daily) with placebo. Rate of growth was significantly slower in the beclometasone group than the placebo group, (0.013 cm/day compared with 0.017 cm/day). After 12 months, the children in the beclometasone group had grown 5 cm and those in the placebo group 5.9 cm [Skoner et al, 2000].

A year-long RCT, in 98 children 3–9 years of age, compared intranasal mometasone with placebo. After 12 months, the mean increase in height was 6.95 cm in the mometasone group, compared with 6.35 cm in the placebo group (p = 0.02) [Schenkel et al, 2000].

A year-long RCT, in 150 children 3.5–9 years of age, which compared intranasal fluticasone (200 micrograms daily) with placebo, found a 6.4-cm height increase in both groups [Allen et al, 2002].

A year-long RCT compared intranasal budesonide (64 micrograms once daily) with placebo in 229 children 4–8 years of age. After 1 year, the mean growth velocity was 5.91 cm/year in the budesonide group and 6.19 cm/year in the placebo group. However, the mean difference (0.27 cm) was not statistically significant [Murphy et al, 2006].

In a small study of 24 children (6–14 years of age) using intranasal triamcinolone, the children followed their age-appropriate growth velocities [Ober et al, 2004].

In conclusion, these studies show that twice daily beclometasone can slow growth velocity in children, whilst once daily mometasone, triamcinolone, fluticasone, and budesonide do not affect growth. However, it is not known whether once daily beclometasone also affects growth [London New Drugs Group, 2008].

It is questionable whether the effect seen in these small studies for beclometasone will result in reduced adult height [London New Drugs Group, 2008].

Contraindications and cautions

What contraindications and cautions are associated with intranasal corticosteroids?

Contraindications

Intranasal corticosteroids should not be used in:

The presence of untreated nasal infections (intranasal corticosteroids can be used if the infection is being treated).

After nasal surgery, unless on specialist advice. Intranasal corticosteroids can be used after healing has occurred.

Pulmonary tuberculosis.

Basis for recommendation

Basis for recommendation

These recommendations are based on the British National Formulary [BNF 59, 2010] and a drug reference database [Sweetman, 2009].

Pregnancy and breastfeeding

Can I prescribe inhaled corticosteroids to a woman who is pregnant, planning a pregnancy, or breastfeeding?

Pregnancy

Intranasal corticosteroids can be used in pregnancy. It is unlikely that systemic concentrations will reach clinically important levels.

Breastfeeding

Intranasal corticosteroids can be used during breastfeeding.

Basis for recommendation

Basis for recommendation

CKS found no studies on the effects of intranasal corticosteroids on pregnancy and breastfeeding.

The manufacturer of Nasonex® (mometasone furoate) recommends that, as with other nasal corticosteroids, it should not be used in pregnancy or lactation unless the potential benefit to the woman justifies any potential risk to the woman and the fetus or infant [ABPI Medicines Compendium, 2008a].

There are no adequate or well-controlled studies in pregnant women. Following intranasal administration of the maximal recommended clinical dose, the plasma concentration of mometasone is not measurable; thus fetal exposure is expected to be negligible and the potential for reproductive toxicity very low [ABPI Medicines Compendium, 2008a].

The manufacturer of Flixonase® (fluticasone propionate) recommends that the possible benefits of the drug is weighed against the possible hazards before using it in pregnancy or breastfeeding [ABPI Medicines Compendium, 2010a].

Administration of corticosteroids to pregnant animals can cause abnormalities of fetal development (including cleft palate and intra-uterine growth retardation). However, these effects occurred after very high systemic exposure. In contrast, direct intranasal application ensures minimal systemic exposure.

There may be a very small risk of such effects in the human fetus [ABPI Medicines Compendium, 2010a].

Adverse effects

What are the adverse effects of intranasal corticosteroids?

Local adverse effects

Approximately 10% of people using intranasal corticosteroids develop local adverse effects (including dryness, irritation, and nosebleed; this may require stopping treatment for a while).

Reddening of the skin, rash, itching, headache, and disturbance of smell and taste may also occur.

Nasal ulceration has been reported, mostly with preparations containing fluticasone furoate or mometasone furoate.

Systemic adverse effects

Systemic adverse effects are rare but may occur, especially with high doses prescribed for a long period of time. Adrenal suppression, decreased bone mineral density, increased intra-ocular pressure, cataract, and glaucoma have been reported in people receiving long-term intranasal corticosteroids.

Psychological and behavioural effects (such as psychomotor hyperactivity, sleep disorders, anxiety, depression, and aggression [particularly in children]) have also been reported.

Growth retardation has been reported in children and adolescents receiving licensed doses. Cushing's syndrome has been reported in children receiving long-term corticosteroid nasal drops.

The risk of systemic effects is considered more likely with drops than with sprays, as drops are more likely to be administered incorrectly.

Basis for recommendation

Basis for recommendation

Information on local and systemic adverse effects is from the British National formulary [BNF 59, 2010] and a drug reference database [Sweetman, 2009].

More recently, the Medicines and Healthcare Regulatory Agency (MHRA) has issued a warning to prescribers that psychological and behavioural side effects may occur in association with the use of intranasal corticosteroids [MHRA, 2010].

Minimizing adverse effects

How do I minimize the risks of adverse effects in people using intranasal corticosteroids?

To minimize the adverse effects of intranasal corticosteroids:

Prescribe a nasal spray instead of drops. If nasal drops are indicated or preferred, ensure that they are used correctly.

Prescribe the weakest potency possible, for the shortest period of time.

In children receiving prolonged treatment with high doses of intranasal corticosteroids (especially drops):

Monitor height regularly, using a growth chart. Any slowing of growth rate should prompt a reduction in dose if possible, or referral to a specialist, or both.

Techniques

Nasal spray technique

Advise the person to:

Gently blow the nose to clear it.

Shake the bottle well.

Close off one nostril and put the nozzle in the other, directing it away from the midline. Tilt the head forward slightly and keep the bottle upright.

Squeeze a fine mist into the nose while breathing in slowly. The person should not sniff hard.

Breathe out through the mouth.

Take a second spray in the same nostril then repeat this procedure for the other nostril.

Nasal drops technique

Advise the person to:

Gently blow the nose to clear it.

Shake the container well.

Tilt the head backwards.

Place the drops in the nostril (squeeze the container gently if necessary).

Keep the head tilted and sniff gently to let the drops penetrate.

Repeat for the other nostril if required.

Basis for recommendation

Basis for recommendation

Most of the recommendations on minimizing adverse effects are based on published expert opinion [Scadding et al, 2008], the British National Formulary [BNF 59, 2010], and a drug reference database [Sweetman, 2009].

Nasal drops — betamethasone drops have a higher systemic bioavailability, and therefore a greater potential for adverse effects, than other intranasal corticosteroids [Scadding et al, 2008]. The risk of systemic effects is more likely with drops than sprays, as these are more likely to be administered incorrectly [BNF 59, 2010]. Fluticasone nasal drops are considered to have an extremely low systemic bioavailability [ABPI Medicines Compendium, 2009b].

The Commission on Human Medicines (formerly the Committee on Safety of Medicines) recommends that the height of children receiving high doses of intranasal steroids over extended periods be frequently monitored, and treatment reviewed if any effect on growth is observed [CSM, 1998].

Techniques for the use of nasal drops and sprays is from a manufacturer's Patient Information Leaflets [ABPI Medicines Compendium, 2008b; ABPI Medicines Compendium, 2010b].

Information and advice

What information and advice should I give to a person receiving intranasal corticosteroids?

Advise the person that:

Intranasal corticosteroids should be used regularly, once or twice daily, for effective control of symptoms.

They may not notice any benefit from the treatment for 3–4 days (maximum benefits may require several weeks of continuous treatment).

Intranasal corticosteroids (especially drops) should be used correctly to avoid systemic absorption and adverse effects.

They should stop using the intranasal corticosteroid if they experience local adverse effects (such as nose bleed or nasal irritation).

Treatment can be recommenced when the adverse effects settle. However, if this occurs regularly, they should seek advice.

Basis for recommendation

Basis for recommendation

These recommendations are based on the British National Formulary [BNF 59, 2010].

The recommendation to stop intranasal corticosteroid if local adverse effects occur, and continuing when the adverse effects settle, is based on what CKS considers to be good practice.

Scenario: Eye treatment

Scenario: Eye treatment

0months3060monthsBoth

Initiation

What do I need to know about the initiation of corticosteroid eye preparations?

Treatment with corticosteroid eye preparations should aways be initiated in secondary care by a specialist. However, treatment may be continued and monitored in primary care, following a management plan agreed with the specialist.

Basis for recommendation

Basis for recommendation

This recommendation is based on the British National Formulary [BNF 59, 2010], and a drug reference database [Sweetman, 2009].

Corticosteroid eye preparations should normally be used only under expert supervision, as there are three main dangers associated with their use [BNF 59, 2010]:

An undiagnosed red eye may be due to herpes simplex virus, and the use of corticosteroid eye preparations may worsen the condition, leading to corneal ulceration and possible loss of vision. The same risks may be seen with bacterial, fungal, and amoebic infections.

Susceptible individuals may develop steroid-induced glaucoma following the use of corticosteroid eye preparations.

Steroid-induced cataract may follow prolonged use of corticosteroid eye preparations.

Contraindications and cautions

What contraindications and cautions are associated with corticosteroid eye preparations?

Treatment with corticosteroid eye preparations should always be initiated in secondary care by a specialist. However, treatment may be continued and monitored in primary care, following a management plan agreed with the specialist.

Contraindications

Corticosteroid eye preparations should be avoided in people with:

Ocular fungal disease, ocular tuberculosis, an untreated and purulent eye infection, amoebic infection, or viral eye infection.

Ocular herpes simplex infection.

Ocular trauma (such as ulcer).

Soft contact lenses — lenses should be removed before instillation of drops, and not worn during the period of treatment.

Caution

Corticosteroid eye preparations should be used with caution in people with glaucoma.

Basis for recommendation

Basis for recommendation

These recommendations are based on manufacturers' Summary of Product Characteristics [ABPI Medicines Compendium, 2009a; ABPI Medicines Compendium, 2010c], the British National Formulary [BNF 59, 2010], and a drug reference database [Sweetman, 2009].

Corticosteroid eye preparations should normally be used only under expert supervision, as there are three main dangers associated with their use [BNF 59, 2010]:

An undiagnosed red eye may be due to herpes simplex virus, and the use of corticosteroid eye preparations may worsen the condition, leading to corneal ulceration and possible loss of vision. The same risks may be seen with bacterial, fungal, and amoebic infections.

Susceptible individuals may develop steroid-induced glaucoma following the use of corticosteroid eye preparations.

Steroid-induced cataract may follow prolonged use of corticosteroid eye preparations.

Soft contact lenses should be removed before instillation of corticosteroids and can be put back in after 15 minutes [ABPI Medicines Compendium, 2009a].

Adverse effects

What are the adverse effects of corticosteroid eye preparations?

Local adverse effects

Corneal ulceration and scarring — can occur in people with ocular herpes simplex, so corticosteroid eye preparations should be avoided in such cases.

Increased intraocular pressure — screen regularly.

Cataract formation and thinning of the cornea and sclera — if the person is receiving long-term corticosteroid eye preparations, refer them to the community optician to screen for cataract formation, ocular hypertension, and other eye problems.

Blurring of vision — this is transient and clears within minutes.

Increased susceptibility to microbial infections and uveitis.

Systemic adverse effects

Systemic adverse effects are rare but may occur, particularly with high doses prescribed for prolonged periods.

Basis for recommendation

Basis for recommendation

These recommendations are based on manufacturers' Summary of Product Characteristics [ABPI Medicines Compendium, 2010c], the British National Formulary [BNF 59, 2010], and a drug reference database [Sweetman, 2009].

Increased intraocular pressure

About 30% of people receiving corticosteroid eye preparations develop increased intraocular pressure, leading to steroid-induced glaucoma (within a few weeks of treatment with potent corticosteroids, or within a few months with weaker corticosteroids).

Information and advice

What information and advice should I give to a person receiving corticosteroid eye preparations?

Advise the person that:

They may experience transient blurred vision after instillation of the eye drops. They should not drive or operate heavy machinery until their vision is clear.

Corticosteroid eye preparations should not be used while wearing soft contact lenses.

Basis for recommendation

Basis for recommendation

These recommendations are based on the British National Formulary [BNF 59, 2010] and a drug reference database [Sweetman, 2009].

Soft contact lenses should be removed before instillation of the corticosteroid and can be put in after about 15 minutes [ABPI Medicines Compendium, 2009a].

Evidence

Evidence

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of corticosteroids.

Search dates

Date unrestricted – March 2010

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

topical corticosteroid$.tw., (topical and corticosteroid).tw., (topical adj2 corticosteroid).tw.

Table 1 . Key to search terms.
Search commands Explanation
/ indicates a MeSh subject heading with all subheadings selected
.tw indicates a search for a term in the title or abstract
exp indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$ indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Sources of guidelines

National Institute for Health and Care Excellence (NICE)

Scottish Intercollegiate Guidelines Network (SIGN)

National Guidelines Clearinghouse

New Zealand Guidelines Group

British Columbia Medical Association

Canadian Medical Association

Institute for Clinical Systems Improvement

Guidelines International Network

National Library of Guidelines

National Health and Medical Research Council (Australia)

Alberta Medical Association

University of Michigan Medical School

Michigan Quality Improvement Consortium

Royal College of Nursing

Singapore Ministry of Health

Health Protection Agency

National Resource for Infection Control

CREST

World Health Organization

NHS Scotland National Patient Pathways

Agency for Healthcare Research and Quality

TRIP database

Patient UK Guideline links

UK Ambulance Service Clinical Practice Guidelines

RefHELP NHS Lothian Referral Guidelines

Medline (with guideline filter)

Driver and Vehicle Licensing Agency

Sources of systematic reviews and meta-analyses

The Cochrane Library :

Systematic reviews

Protocols

Database of Abstracts of Reviews of Effects

Medline (with systematic review filter)

EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

NIHR Health Technology Assessment programme

The Cochrane Library :

NHS Economic Evaluations

Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health

International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

The Cochrane Library :

Central Register of Controlled Trials

Medline (with randomized controlled trial filter)

EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Bandolier

Drug & Therapeutics Bulletin

MeReC

NPCi

BMJ Clinical Evidence

DynaMed

TRIP database

Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

Department of Health

Health Management Information Consortium (HMIC)

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

British National Formulary (BNF)

electronic Medicines Compendium (eMC)

European Medicines Agency (EMEA)

LactMed

Medicines and Healthcare products Regulatory Agency (MHRA)

REPROTOX

Scottish Medicines Consortium

Stockley's Drug Interactions

TERIS

TOXBASE

Micromedex

UK Medicines Information

References

ABPI Medicines Compendium (2007) Summary of product characteristics for Betnovate ointment. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2008a) Summary of product characteristics for Nasonex 50 micrograms/actuation nasal spray, suspension. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2008b) Flixonase aqueous nasal spray. Patient information leaflet. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2009a) Summary of product characteristics for Lotemax 0.5% eye drops, suspension. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2009b) Summary of product characteristics for Flixonase nasule drops. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2010a) Summary of product characteristics for Flixonase aqueous nasal spray. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2010b) Flixonase nasule drops. Patient information leaflet. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

ABPI Medicines Compendium (2010c) Summary of product characteristics for Maxidex. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

Allen, D.B., Meltzer, E.O., Lemanske, R.F. et al. (2002) No growth suppression in children treated with the maximum recommended dose of fluticasone propionate aqueous nasal spray for one year. Allergy and Asthma Proceedings 23(6), 407-413. [Abstract]

Beattie, P.E. and Lewis-Jones, M.S. (2003) Parental knowledge of topical therapies in the treatment of childhood atopic dermatitis. Clinical and Experimental Dermatology 28(5), 549-553. [Abstract]

Birnie, A.J., Bath-Hextall, F.J., Ravenscroft, J.C. and Williams, H.C. (2008) Interventions to reduce Staphylococcus aureus in the management of atopic eczema (Cochrane Review). The Cochrane Library. Issue 3. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]

BNF 59 (2010) British National Formulary. 59th edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.

Chi, C.C., Lee, C.W., Wojnarowska, F. and Kirtschig, G. (2009) Safety of topical corticosteroids in pregnancy (Cochrane Review). The Cochrane Library. Issue 3. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]

CHM (2006) High dose inhaled steroids: new advice on supply of steroid treatment cards. Current Problems in Pharmacovigilence 31(May), 5. [Free Full-text]

Coulson, I. (1996) Topical steroids for skin disease. Dermatology in Practice 4(2), 5-9.

CSM (1998) The safety of inhaled and nasal corticosteroids. Current Problems in Pharmacovigilance 24(May), 8-9. [Free Full-text]

Dermatology UK (2007) Best practice in emollient therapy: a statement for healthcare professionals. Dermatology UK Ltd. [Free Full-text]

London New Drugs Group (2008) Intranasal corticosteroids for allergic rhinitis. London Medicines Information Service. www.evidence.nhs.uk

Long, C.C., Mills, C.M. and Finlay, A.Y. (1998) A practical guide to topical therapy in children. British Journal of Dermatology 138(2), 293-296. [Abstract]

Menter, A. and Griffiths, C.E. (2007) Current and future management of psoriasis. Lancet 370(9583), 272-284. [Abstract]

Menter, A., Korman, N.J., Elmets, C.A. et al. (2009) Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. Journal of the American Academy of Dermatology 60(4), 643-659. [Abstract] [Free Full-text]

MeReC (1998) The use of emollients in dry skin conditions. MeReC Bulletin 9(12), 45-48. [Free Full-text]

MeReC (1999) Using topical corticosteroids in general practice. MeReC Bulletin 10(6), 21-24. [Free Full-text]

MHRA (2010) Inhaled and intranasal corticosteroids: risk of psychological and behavioural side effects. Drug Safety Update 4(2), A4. [Free Full-text]

Murphy, K., Uryniak, T., Simpson, B. and O'Dowd, L. (2006) Growth velocity in children with perennial allergic rhinitis treated with budesonide aqueous nasal spray. Annals of Allergy, Asthma and Immunology 96(5), 723-730. [Abstract]

National Collaborating Centre for Women's and Children's Health (2007) Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years (full NICE guideline). . Clinical guideline 57. National Institute for Health and Care Excellence. www.nice.org.uk [Free Full-text]

NICE (2004) Frequency of application of topical corticosteroids for atopic eczema (NICE technology appraisal 81). National Institute for Health and Care Excellence. www.nice.org.uk [Free Full-text]

Ober, S., Gentil, D., Kairis, E. et al. (2004) Growth velocity and HPA axis function during 1-year treatment with Triamcinolone Acetonide Aqueous (TAA) nasal spray in children with allergic rhinitis (AR). Journal of Allergy and Clinical Immunology 115(2), S267.

Rang, H.P., Dale, M.M., Ritter, J.M. and Flower, R.J. (2007) Rang and Dale's pharmacology. 6th edn. Edinburgh: Churchill Livingstone.

Scadding, G.K., Durham, S.R., Mirakian, R. et al. (2008) BSACI guidelines for the management of allergic and non-allergic rhinitis. Clinical and Experimental Allergy 38(1), 19-42. [Abstract] [Free Full-text]

Schaefer, C., Peters, P. and Miller, R.K. (Eds.) (2007) Drugs during pregnancy and lactation: treatment options and risk assessment. 2nd edn. Oxford: Academic Press.

Schenkel, E.J., Skoner, D.P., Bronsky, E.A. et al. (2000) Absence of growth retardation in children with perennial allergic rhinitis after one year of treatment with mometasone furoate aqueous nasal spray. Pediatrics 105(2), E22. [Abstract] [Free Full-text]

SIGN (2011) Management of atopic eczema in primary care. Scottish Intercollegiate Guidelines Network. www.sign.ac.uk [Free Full-text]

Skoner, D.P., Rachelefsky, G.S., Meltzer, E.O. et al. (2000) Detection of growth suppression in children during treatment with intranasal beclomethasone dipropionate. Pediatrics 105(2), E23. [Abstract] [Free Full-text]

Sweetman, S.C. (2009) Martindale: the complete drug reference. MICROMEDEX [CD-ROM]. Vol 139.London: Thomson Reuters Healthcare.

van de Kerkhof, P.C., Barker, J., Griffiths, C.E. et al. (2008) Psoriasis: consensus on topical therapies. Journal of The European Academy of Dermatology and Venereology 22(7), 859-870. [Abstract]

Walker, R. and Edwards, C. (Eds.) (1999) Clinical Pharmacy and Therapeutics. 2nd edn. Edinburgh: Churchill Livingstone.

Warner, M. and Camisa, C. (2001) Topical corticosteroids. In: Wolverton, S.E. (Ed.) Comprehensive dermatologic drug therapy. : Saunders. 548-577.

Weatherhead, S., Robson, S. and Reynolds, S.C. (2007) Management of psoriasis in pregnancy. BMJ 334(7605), 1218-1220. [Free Full-text]

WHO (2002) Breastfeeding and maternal medication. World Health Organization. www.who.int [Free Full-text]

Williams, H.C. (2005) Clinical practice: atopic dermatitis. New England Journal of Medicine 352(22), 2314-2324.

Williams, H.C. (2007) Established corticosteroid creams should be applied only once daily in patients with atopic eczema. British Medical Journal 334(7606), 1272. [Free Full-text]

Wolverton, S.E. (2001) Basic pharmacologic principles. In: Wolverton, S.E. (Ed.) Comprehensive dermatologic drug therapy. : Sunders. 2-14.

Yawn, B. (2006) Comparison of once-daily intranasal corticosteroids for the treatment of allergic rhinitis: are they all the same? MedGenMed 8(1), 23. [Abstract]