4 questions about corticosteroid creams for atopic dermatitis

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As I mentioned in another post about atopic dermatitis and its treatment, one of the mainstays of treatment is corticosteroid creams, emulsions or ointments. In people with this disease, the balance of benefits and risks of this treatment is clearly on the side of benefit, although it is important to be aware that corticosteroid creams are a drug and not just another moisturizer; therefore, their use should be indicated by a pediatrician or dermatologist.

In atopic dermatitis, the benefit of topical corticosteroids outweighs their risks.

The purpose of this article is not to scare people about the risks of topical corticosteroids, but rather to provide information to help alleviate some of the (unfounded) fears surrounding this very useful and important treatment for people with atopic dermatitis.

The purpose of this post is to inform and reassure about the use of corticosteroid creams.

1. How do topical corticosteroids work in atopic dermatitis?

Topical corticosteroids are used primarily for their anti-inflammatory effects. The drug penetrates the inflammatory cells found in dermatitis skin and reduces certain mechanisms that cause inflammation locally. They are usually used when basic hygiene and hydration measures are not sufficient. More than one hundred randomized clinical trials (the highest quality scientific studies) have been published in the scientific literature demonstrating their efficacy for atopic dermatitis.

Topical corticosteroids act by reducing inflammation and are classified according to their potency.

There are 7 groups into which they are divided according to their potency in reducing inflammation. The dermatologist (this could be done through a consultation with an online dermatologist) will indicate the most appropriate depending on where it should be used and for how long.

2. WHAT ARE THE SKIN RISKS?

In general, the risk of topical corticosteroids is very low, especially when used according to a dermatologist’s guidelines. I will describe below the problems that can occur as a result of their use, but I would like to make it clear that they are all generally due to inappropriate and abusive use over very long periods of time. Even when atopic dermatitis lasts for years and repeated cycles of one or more topical corticosteroids are performed, it is rare to achieve any of the effects you will read about below.

CUTANEOUS ATROPHY: The use of strong corticosteroids (which we rarely prescribe, especially in children) can cause skin atrophy. This is a significant thinning of the skin, which resembles cigarette paper, and can cause stretch marks, which can make the veins under the skin more visible.

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This is extremely rare in the treatment of atopic dermatitis because super-potent corticosteroids are not usually used, and if they are used, it is on an ad hoc basis. One study showed that continuous use of fluticasone (one of the most commonly used corticosteroids in children) on the same skin for 10 weeks did not cause atrophy.

ROSACEA-LIKE ERUPTION: Continuous use on the face can cause the appearance of pimples and pinker skin in the area of use, which is almost indistinguishable from rosacea, which I will talk about in another post. This is usually seen in adults who have been using a corticosteroid on the face for years without medical control and is therefore extremely rare in children.

OTHER SKIN CHANGES: Other less common skin changes may include lightening of the skin color (e.g., in Asia and Africa, they have been used to depigment the skin) or the appearance of more hair.

It is common in children with atopic dermatitis to see areas of lighter skin, which tends to be more noticeable in the summer. This color change is called dartros or pityriasis alba and is due to the atopic dermatitis itself and not to topical corticosteroids, as is often thought.

CORTICOID ALLERGY: It is very rare, but it is possible to be allergic to a certain type of corticosteroid cream; this is suspected when a person does not improve at all or even gets worse after using a certain corticosteroid. As I said, it is rare, but if it is suspected, specific tests should be done to confirm it.

3. What are the risks to the REST OF THE BODY?

You may have heard many times that corticosteroids (or as they say, “cortisone”) are bad because they can raise blood pressure, make us swell or cause diabetes (elevated blood sugar). These are well-known side effects of corticosteroids, but they usually occur with long, systemic (i.e., oral or intravenous) treatments.

It is very rare for topical corticosteroids to cause systemic effects after appropriate use.

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When applying a cream, emulsion, or ointment, depending on the area of the body, some of the medication may enter the bloodstream, but this amount is negligible in most cases. However, this should be taken into account in areas such as the folds of the skin, the genitals, or the eyelids, where the skin is so thin that the proportion of the drug that enters the blood is greater (compared to, for example, areas such as the palms of the hands or the forehead). In any case, it never reaches half of the amount applied.

Therefore, it is rare for blood levels to cause the typical manifestations of systemic corticosteroids. In any case, we have to keep in mind that this could happen if the treatment is abused; therefore, it is important to follow the advice of a dermatologist (whether online or in person) who will adjust the dose and type of corticosteroid according to the area or extent where it is to be applied.

4. ARE THERE ALTERNATIVES to its use?

There are alternative treatments to topical corticosteroids, but in my opinion they should not replace corticosteroids, but may be useful to supplement treatment in some cases.

Topical pimecrolimus and tacrolimus are alternative treatments to topical corticosteroids.

These treatments are topical calcineurin inhibitors (tacrolimus and pimecrolimus). These are also medications that have been shown to be safe in the long term, but I will discuss them in more detail in another post.

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