Crew AB. Dermatology in Rheumatology Practice. Presented at: Congress of Clinical Rheumatology-East annual symposium; September 10-13, 2020 (virtual meeting).
Dermatologist: Keep these three topical steroids 'in your back pocket'
Common “pitfalls” among rheumatologists when prescribing topical steroids include doses that are too weak or low in volume, and a failure to advise patients on side effects, said a speaker at the 2020 Congress of Clinical Rheumatology-East.
“Some of the common pitfalls that I see, and that a lot of dermatologists see when non-dermatologists prescribe steroids include, first, that it’s often that the steroids are too weak,” said Ashley B. Crew, MD, an associate professor of dermatology and co-director of the Rheumatology-Dermatology Clinic at the University of Southern California Keck School of Medicine. “The patient may have a very thick psoriatic plaque, and they’ve been prescribed some hydrocortisone, but dermatologists know there are stronger options that are more efficacious.
“It’s also not uncommon that patients are prescribed volumes that are too low,” Crew said. “If we have a patient with erythrodermic psoriasis who has been started on a biologic but needs some topical therapy to bridge them, if they get a little 15-gram tube, we know that won’t last them very long. So, we can employ things like prescribing a jar of triamcinolone instead of a little, tiny tube. Also, I know that, while we usually vary off toward being too conservative with steroids, sometimes patients are given a lot of topical steroids but they are not educated about the potential side effects that they should know about.”
Topical steroids range in strength from class 1, the weakest, to class 7, the strongest. According to Crew, having a weak, a medium and a strong topical steroid “in your back pocket” is good practice and can prepare rheumatologists for most clinical scenarios. She suggested hydrocortisone 2.5% as a weak steroid, triamcinolone 0.1% as a medium option, and fluocinonide 0.05% as a strong steroid.
Factors to consider when choosing a strength include the location on the body where the medication will be applied — no stronger than a class 5 on the face and thin-skinned areas, said Crew — and the pathology to be treated. Faint rashes rarely require a robust treatment, whereas thick psoriatic plaques will require a stronger option.
Crew said she directs patients to apply to the affected areas twice a day for up to 2 weeks, and then every Monday through Friday at maximum.
“If someone is kind of acutely distressed, it is OK to use this back-to-back-days regimen for about 2 weeks, but when we are talking about more prolonged use, the general principle is that you want an average of 1 week of the month to be not using the topical steroids,” Crew said. “That is to prevent tachyphylaxis. I find it easier to ask the patients to take the weekends off, rather than 3 weeks on and 1 week off, like some providers do. Also, if it is a very strong topical steroid, I will also specify, ‘Do not apply to face, groin and armpits.’”
Regarding volume, Crew advises rheumatologists to be aware of the size of the prescription tube they are providing, and whether it is adequate for their patient. For example, a once-daily application to the front-side of a patient’s torso for 10 days will likely require a 45g or 50g tube, she said. Meanwhile, a 10-day regimen for just one arm may require a 15g tube.
According to Crew, the amount of ointment that can stretch from the distal crease to the tip of the finger is roughly 0.5g and is known as a fingertip unit (FTU). When judging treatment volume, rheumatologists should consider that 1 FTU can cover approximately 2% of the body’s surface area, Crew said. This comes out to 20g for the entire body, or 250g per week if used twice daily.
Lastly, although topical steroids have boasted an “excellent safety record” throughout their 30-year history of use, rheumatologists should advise their patients on several common adverse effects, Crew said. These can include skin atrophy, which can occur on the armpit, groin and other thin-skin areas, as well as the face. Other common adverse effects include rosacea or perioral dermatitis; dermatitis, acne or folliculitis; tachyphylaxis or rebound; and hypopigmentation.
Less common adverse events can include allergic contact dermatitis, impaired wound healing, tinea or scabies incognito, glaucoma or cataracts, and hypertrichosis.
“Topical steroids have been used for more than 30 years with an excellent safety record, which is reassuring, but there are side effects and things we want to avoid,” Crew said. “I hope one or two of these tips I provided resonates with you and can be helpful for you in your day-to-day practice.”