A Penny Pincher's Guide to Topical CorticosteroidsAlthough topical corticosteroid therapy can be highly effective, such treatment can be costly--especially whenbrand-name products are prescribed for extensive or chronic conditions. Here we describe an economical approachthat does not sacrifice either efficacy or safety.Do's and Don'ts of Economical Topical Corticosteroid Therapy
- Prescribe generic products. The equivalent brandnameproducts may be more effective, but the increasein efficacy usually does not justify the added cost. If yourinitial choice is not sufficiently effective, change to ahigher-strength generic (Table 1). Switch to the brandnameagent only when the higher-strength generic doesnot work.
- For most conditions, use triamcinolone 0.1% as a firstchoiceagent. It is a product of medium potency that isavailable in large sizes and as both cream and ointment;it is also one of the lowest in cost. (For severe cases, itis reasonable to start with a higher strength.)
- Prescribe enough. Keep in mind that chronic conditionsneed long-term treatment and hence large quantities(15 g = 1 hand side tid x 2 wk). A 1-lb tube--if available--may be the best option in such a setting. Forinitial trials, however, it may be wise to use a small size.
- Pharmacists may have to special-order larger tubes;advise patients to insist that the amount you prescribebe filled with a single tube whenever possible ratherthan with multiple smaller tubes.
- Use ointment preferentially, except on the scalp, onthe face, in intertriginous areas, and on very hairyareas. An ointment is generally more effective than thecream of equivalent concentration, but a bit greasy.When greasiness is a problem, prescribe ointment foruse at bedtime and cream for daytime use.
- Use gels, lotions, or solutions for hairy areas (Table 2).
- If corticosteroids won't work, don't use them. Someof the conditions in which corticosteroids are known tobe ineffective include scabies, tinea, candidal infections,herpes, neurotic excoriations, and dry skin. Any efficacythat may be seen is likely attributable to the vehicle.Urticaria, insect bites, and sunburn also frequently respondpoorly to corticosteroids.
- Don't use high-potency agents in intertriginous areas,on the face, on the genitals, or under occlusion. Such usecan result in increased skin atrophy or systemic absorption.In general, use high-potency agents with caution inchildren and older patients.
- Don't use a high-potency agent for more than 2 to 3weeks. After this amount of time, give the patient a 2-weekbreak before resuming treatment. In addition, limit highpotencyagents to a maximum of 50 g/wk for small areas.
- Application 3 times daily--or less frequently--is usuallysufficient. Even once-daily application may suffice (eg,an ointment applied daily at bedtime).
- Instruct patients to apply creams sparingly; theyshould use quantities that will vanish when rubbed inlightly.
- Use pulse dosing when treating chronic or resistantconditions with high-potency agents that are not availablein economical large sizes. For example, prescribethe high-potency agent for weekend use only and alower-potency agent (that is available in larger sizes)for use during the week.
- For resistant areas, use the prescribed product withocclusion (plastic wrap) when possible. For localizeddermatitis, consider a hydrocolloid dressing or a transparentthin film dressing over the corticosteroid for3 to 7 days.
- Beware of the potential for allergy or irritation. Considerstopping treatment for a while if the condition getsworse or does not respond.
FOR MORE INFORMATION:
- Habif TP. Skin Disease Diagnosis and Treatment. St Louis: Mosby; 2001:chap 1.