BNF for Children 2011-2012

BNFC 2011–2012 13.4 Topical corticosteroids 559. severe eczema of the face and neck—moderatelypotent corticosteroid for 3–5 days only, if not controlledby a mild corticosteroid;. severe eczema on the trunk and limbs—moderatelypotent or potent corticosteroid for 1–2 weeks only,switching to a less potent preparation as the conditionimproves;. eczema affecting area with thickened skin (e.g.soles of feet)—potent topical corticosteroid in combinationwith urea or salicylic acid (to increasepenetration of corticosteroid).Perioral lesions Hydrocortisone cream 1% can beused for up to 7 days to treat uninfected inflammatorylesions on the lips. Hydrocortisone and miconazolecream or ointment is useful where infection by susceptibleorganisms and inflammation co-exist, particularlyfor initial treatment (up to 7 days) e.g. in angular cheilitis(see also p. 545). Organisms susceptible to miconazoleinclude Candida spp. and many Gram-positive bacteriaincluding streptococci and staphylococci.Cautions Avoid prolonged use of a topical corticosteroidparticularly on the face (and keep away fromeyes). Use potent or very potent corticosteroids underspecialist supervision; extreme caution is required indermatoses of infancy including nappy rash—treatmentshould be limited to 5–7 days.Psoriasis The use of potent or very potent corticosteroids inpsoriasis can result in rebound relapse, development of generalisedpustular psoriasis, and local and systemic toxicity, seenotes above.Contra-indications Topical corticosteroids are contra-indicatedin untreated bacterial, fungal, or viral skinlesions, in acne, and in perioral dermatitis; potent corticosteroidsare contra-indicated in widespread plaquepsoriasis (see notes above).Side-effects Mild and moderately potent topicalcorticosteroids are associated with few side-effects butparticular care is required when treating neonates andinfants, and in the use of potent and very potent corticosteroids.Absorption through the skin can rarely causeadrenal suppression and even Cushing’s syndrome (section6.3.2), depending on the area of the body beingtreated and the duration of treatment. Absorption ofcorticosteroid is greatest from severely inflamed skin,thin skin (especially on the face or genital area), fromflexural sites (e.g. axillae, groin), and in infants whereskin surface area is higher in relation to body-weight;absorption is increased by occlusion. Local side-effectsinclude:. spread and worsening of untreated infection;. thinning of the skin which may be restored over aperiod after stopping treatment but the originalstructure may never return;. irreversible striae atrophicae and telangiectasia;. contact dermatitis;. perioral dermatitis;. acne, or worsening of acne or rosacea;. mild depigmentation which may be reversible;. hypertrichosis also reported.Children and their carers should be reassured that sideeffects such as skin thinning and systemic effects rarelyoccur when topical corticosteroids are used appropriately.Safe PracticeIn order to minimise the side-effects of a topicalcorticosteroid, it is important to apply it thinly toaffected areas only, no more frequently than twicedaily, and to use the least potent formulation whichis fully effective.Application Topical corticosteroid preparationsshould be applied no more frequently than twice daily;once daily is often sufficient.Topical corticosteroids should be spread thinly on theskin but in sufficient quantity to cover the affected areas.The length of cream or ointment expelled from a tubemay be used to specify the quantity to be applied to agiven area of skin. This length can be measured in termsof a fingertip unit (the distance from the tip of the adultindex finger to the first crease). One fingertip unit(approximately 500 mg) is sufficient to cover an areathat is twice that of the flat adult palm.If a child is using topical corticosteroids of differentpotencies, the child and their carers should be told whento use each corticosteroid. The potency of each topicalcorticosteroid (see Topical Corticosteroid PreparationPotencies, below) should be included on the label withthe directions for use. The label should be attached tothe container (for example, the tube) rather than theouter packaging.Mixing topical preparations on the skin should beavoided where possible; several minutes should elapsebetween application of different preparations.Compound preparations The advantages of includingother substances (such as antibacterials or antifungals)with corticosteroids in topical preparationsare uncertain, but such combinations may have aplace where inflammatory skin conditions are associatedwith bacterial or fungal infection, such as infectedeczema. In these cases the antimicrobial drug should bechosen according to the sensitivity of the infectingorganism and used regularly for a short period (typicallytwice daily for 1 week). Longer use increases the likelihoodof resistance and of sensitisation.The keratolytic effect of salicylic acid facilitates theabsorption of topical corticosteroids; however, excessiveand prolonged use of topical preparations containingsalicylic acid may cause salicylism.Topical corticosteroid potenciesPotency of a topical corticosteroid preparation dependsupon the formulation as well as the corticosteroid.Therefore, proprietary names are shown below.MildHydrocortisone 0.1–2.5%, Dioderm, Mildison,Synalar 1 in 10 DilutionMild with antimicrobials Canesten HC,Daktacort, Econacort, Fucidin H, Nystaform-HC, TimodineMild with crotamiton Eurax-Hydrocortisone13 Skin