Skin Deep

It’s time for this blog to live up to its name and do a dermatology post.   Today… topical steroids.  This was always kind of a black box for me, I never knew which steroid to pick, and sort of did so randomly.  But there is some method to the madness if you understand relative potency.  Target the condition and the location with the right potency and you will be in good shape.  The thicker the skin or the “thicker” the dermatitis, the higher potency medicine you will need to penetrate it.  Also, higher potency creams come with higher risk for side effects- thinning skin, telangiectasias, and even systemic absorption.  So use them sparingly and for a short a time as possible.
A word about vehicles.  The more “goopy” an agent is, the more potent.

There are some other interesting vehicles available.  In general, a gel will give the potency of the ointment without the grease factor.  Foams are handy for hairy areas- Clobetasol (Olux) foam is
useful for thick seborrheic dermatitis or psoriasis in the hairline. 

You can also increase the potency by putting something under occlusion, either by covering it with an emollient like Vaseline or by simply covering it with a bandage, or the ever helpful white cotton sock.

On with the list. I would suggest learning one or two choices for a super high, high, and low potency steroid and just stick to those.  I’ve added some brand names below because those are easier to remember. Simplify, simplify, simplify…

Super High Potency: Class 1 
Think thick: thick skin or thick plaques of dermatitis
Location: palms and soles
Disease: severe dermatitis (contact or allergic/eczema), psoriasis
Duration: less than 3 weeks
Agents: Betamethasone diproprionate(Diprolene), Clobetasol proprionate (Temovate or Olux foam)
High Potency: Classes 2-3 
Location: arms/legs, back, trunk
Duration: 6-8 weeks
Agents: 0.5% triamcinolone ointment (Kenalog), Fluocinonide (Lidex)
Medium Potency: Classes 4-5
Location: face, intertriginous areas, large areas (risk of systemic absorbtion)
Agents: 0.1% triamcinolone ointment (Aristocort), 0.1% Hydrocortisone butyrate (Locoid)
Low Potency: Classes 6-7. 
Think thin: thin skin, not much disease. This is where the OTC steroid creams are.  
Location: eyelid, genitalia 
Agents: 0.5% Hydrocortisone base (Cortaid)
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