BNF for Children 2011-2012

558 13.4 Topical corticosteroids BNFC 2011–201213 SkinPregnancy manufacturer advises use only if potentialbenefit outweighs riskBreast-feeding manufacturer advises use only ifpotential benefit outweighs riskSide-effects drowsiness; local burning, stinging, irritation,tingling and rash; systemic side-effects such asantimuscarinic affects, headache, fever, dizziness,gastro-intestinal disturbances also reportedIndication and dosePruritus in eczemaChild 12–18 years apply thinly 3–4 times daily;usual max. 3 g per application; usual total max.12 g daily; coverage should be less than 10% ofbody surface areaDepressive illness section 4.3.1Xepin c (CHS) ACream, doxepin hydrochloride 5%, net price 30 g =£11.70. Label: 2, 10, patient information leafletExcipients include benzyl alcohol13.4 Topical corticosteroidsTopical corticosteroids are used for the treatment ofinflammatory conditions of the skin (other than thosearising from an infection), particularly eczema (section13.5.1), contact dermatitis, insect stings (p. 34), andeczema of scabies (section 13.10.4). Corticosteroidssuppress the inflammatory reaction during use; theyare not curative and on discontinuation a reboundexacerbation of the condition may occur. They aregenerally used to relieve symptoms and suppresssigns of the disorder when other measures such asemollients are ineffective.Children, especially infants, are particularly susceptibleto side-effects. However, concern about the safety oftopical corticosteroids in children should not result inthe child being undertreated. The aim is to control thecondition as well as possible; inadequate treatment willperpetuate the condition. Carers of young childrenshould be advised that treatment should not necessarilybe reserved to ‘treat only the worst areas’ and they mayneed to be advised that patient information leaflets maycontain inappropriate advice for the child’s condition.In an acute flare-up of atopic eczema, it may be appropriateto use more potent formulations of topical corticosteroidsfor a short period to regain control of thecondition. Continuous daily application of a mildcorticosteroid such as hydrocortisone 1% is equivalentto a potent corticosteroid such as betamethasone 0.1%applied intermittently.Topical corticosteroids are of no value in the treatmentof urticaria. They may worsen ulcerated or secondarilyinfected lesions. They should not be used indiscriminatelyin pruritus (where they will only benefit if inflammationis causing the itch) and are not recommendedfor acne vulgaris.Systemic or potent topical corticosteroids should beavoided or given only under specialist supervision inpsoriasis because, although they may suppress the psoriasisin the short term, relapse or vigorous reboundoccurs on withdrawal (sometimes precipitating severepustular psoriasis). Topical use of potent corticosteroidson widespread psoriasis can lead to systemic as well asto local side-effects. It is reasonable, however, to prescribea mild to moderate topical corticosteroid for ashort period (2–4 weeks) for flexural and facial psoriasis,and to use a more potent corticosteroid such asbetamethasone or fluocinonide for psoriasis of thescalp, palms, or soles (see below for cautions in psoriasis).In general, the most potent topical corticosteroidsshould be reserved for recalcitrant dermatoses such aschronic discoid lupus erythematosus, lichen simplexchronicus, hypertrophic lichen planus, and palmoplantarpustulosis. Potent corticosteroids should generallybe avoided on the face and skin flexures, but specialistsoccasionally prescribe them for use on these areas incertain circumstances.When topical treatment has failed, intralesional corticosteroidinjections (section 10.1.2.2) may be used. Theseare more effective than the very potent topical corticosteroidpreparations and should be reserved for severecases where there are localised lesions such as keloidscars, hypertrophic lichen planus, or localised alopeciaareata.Choice Water-miscible corticosteroid creams are suitablefor moist or weeping lesions whereas ointmentsare generally chosen for dry, lichenified or scaly lesionsor where a more occlusive effect is required. Lotionsmay be useful when minimal application to a large orhair-bearing area is required or for the treatment ofexudative lesions. Occlusive polythene or hydrocolloiddressings increase absorption, but also increase the riskof side-effects; they are therefore used only under supervisionon a short-term basis for areas of very thick skin(such as the palms and soles). Disposable nappies andtight fitting pants also increase the risk of side-effects byincreasing absorption of the corticosteroid. The inclusionof urea or salicylic acid also increases the penetrationof the corticosteroid.‘Wet-wrap bandaging’ (section 13.5.1) increases absorptioninto the skin, but should be initiated only by adermatologist and application supervised by a healthcareprofessional trained in the technique.In the BNF for Children, topical corticosteroids for theskin are categorised as ‘mild’, ‘moderately potent’,‘potent’ or ‘very potent’ (see p. 559); the least potentpreparation which is effective should be chosen butdilution should be avoided whenever possible.Topical hydrocortisone is usually used in children under1 year of age. Moderately potent and potent topicalcorticosteroids should be used with great care in childrenand for short periods (1–2 weeks) only. A verypotent corticosteroid should be initiated under thesupervision of a specialist.Appropriate topical corticosteroids for specific conditionsare:. insect bites and stings—mild corticosteroid such ashydrocortisone 1% cream;. inflamed nappy rash causing discomfort in infantover 1 month (section 13.2.2)—mild corticosteroidsuch as hydrocortisone 0.5 or 1% for up to 7 days(combined with antimicrobial if infected);. mild to moderate eczema, flexural and facial eczemaor psoriasis—mild corticosteroid such ashydrocortisone 1%;