Corticosteroid: o topical and systemic Aznan Lelo, Yunita Sari Pane Dep. Farmakologi dan Terapeutik, Fakultas Kedokteran Universitas Sumatera Utara 8&11, 4 Februari 2009, KBK, FK USU, Medan
Dermatitis Atopic dermatitis Diapers dermatitis Contact dermatitis Stasis dermatitis
Symptoms of allergic drug reactions Skin reactions (80%) Anaphylaxis (9-15%) Respiratory symptoms (6-9%) Drug fever (2-6%) Stevens Johnson syndrome
Eczema Treatment Emollients: ointments > creams > lotions Topical corticosteroids Topical Immunomodulators (TIMs): safe for short-term or intermittent long-term Pimecrolimus (Elidel) Tacrolimus (Protopic) Systemic corticosteroids Oral Antihistamines Sedating-AHis Non-sedating-AHis Oral Leukotriene receptor antagonists Monteleukast (Singulair)
STEROID Lipid characterized by a carbon skeleton with four fused rings. All steroids are derived from the acetyl CoA biosynthetic pathway. Systemic Topical
Topical corticosteroids (TCS) First introduced in the 1950s and are currently the mainstay of prescription therapy for atopic dermatitis Safe and effective when used as recommended Weakest steroid that will keep the eczema under control, should be used Potent steroids should be used in short pulses, generally 2-3 weeks
TCS = Topical corticosteroids Drug Topical preparation Potency Beclomethasone 0.025 % cream Potent dipropionate Betamethasone benzoate Betamethasone valerate 0.025 % cream, ointment 0.12 % cream, ointment Potent Clobetasol propionate 0.05 % cream Potent Halcinonide 0.1 cream Potent Triamcinolone actonide 0.1 % ointment Potent Fluocinolone actonide 0.025% ointment Moderate Mometasone 0.1 % cream, ointment Moderate Fluticasone 0.05 % cream Moderate Hydrocortisone acetate 2.5%ointment Moderate Hydrocortisone acetate 0.1 1.0% ointment Mild
Classification of TCS Class Potency Steroid Antiinflam Antimitosi Diseases Disadvantage I Super- Betametason +++ +++ Liken simplex causes thin potent, fast acting dipropionat 0,05 % kronik Hyperkeratosis eksema skin, not safe in kids shortterm use only Mycosis fungoides. LE, resist. eczema II Potent Triamsinolon asetonid 0,1% Betametasone valerate +++ ++ Lichenified eczema, psoriasis Seboroika eksema III Moderate Flumetason ++ + Body, still causes safer for chronic use pivalat 0,02 % extremities thinning over long-term IV Mild Hidrokortison 1 % + - Face, flexures, children, aged people Limited effectiveness
Diprosone (Betamethasone Propionate) Approved in 2001 Betamethasone Propionate 0.05% Class steroid Diprosone Ointment, 0.05% a Class I steroid Diprosone Cream, 0.05% 05% a Class II steroid Diprosone Lotion, 0.05% a Class III steroid
Mechanism of action of TCS 1. Antiinflammatory effects TCS affect inflammatory cells, chemical mediators and tissue responses which are all responsible for cutaneous inflammation 2. Antiproliferative effects (anti-mitotic) TCS may reduce mitotic activity in the epidermis, leading to flattening of the basal cell layer and thinning of the stratum corneum and stratum granulosum 3. Atrophogenic Effects TCS can promote atrophy of the dermis through inhibition of fibroblast proliferation, migration, chemotaxis and protein synthesis
Topical Corticosteroids (TCS) Antiinflammatory effects - TCS inhibit nuclear factor kappa B (NFkB), which upregulates cytokines. Inhibition done by increasing production of NFkB inhibitor (IkB) and directly binding & inactivating NFkB - Affects leukocytes, lymphocytes, monocytes, epidermal Langerhans cells - Inhibit phospholipase A2 and then inhibit PGs & LTs - Vasoconstrictive - Antipruritic - Mast cell sensitization & IgE induced mediator release inhibited Antiproliferative & Atrophogenic effects
GLUCOCORTICOID (CORTISOL : HYDROCORTISONE) MECHANISM OF ACTION Cell membrane Nuclear membrane accceptor Steroid Steroid + receptor complex Steroid + receptor complex receptor chromatin
GLUCOCORTICOID (CORTISOL : HYDROCORTISONE) IMMUNOSUPPRESSIVE AND ANTI-INFLAMMATION EFFECT ANTIGEN-ANTIBODY ANTIBODY COMPLEX PHOSPOLIPID ARACHIDONIC ACID INHIBITED BY GLUCOCORTICOID PHOSPOLIPASE A 2 LIPOXYGENASE CYCLOOXYGENASE LEUKOTRIENE THROMBOXANES PROSTACYCLIN PROSTAGLANDINS
Systemic Effects of TCS If a TCS is absorbed percutaneously in significant quantities, it can cause systemic adverse side effects similar to systemically administered corticosteroids.
Adverse reactions (1/2) Can result from : the drug substance, or the vehicle which can potentiate problems Metabolic toxicity: Iatrogenic Cushing s syndrome Hyperglycaemia, gy gy glycosuria, diabetes Myopathy (negative nitrogen balance) Osteoporosis (vertebral compression fracture) Retardation of growth (children) Hypertension, edema, CCF Avascular necrosis of femur
Adverse reactions (2/2) HPA axis suppression Behavioral toxicity: Euphoria, psychomotor reactions, suicidal tendency Ocular toxicity: it steroid induced glaucoma, posterior subcapsular cataract. Others: Superinfections Delayed wound healing Steroid arthropathy Peptic ulcer Live vaccines are dangerous
Risk factors for systemic adverse effects Young age (infants and children) Liver and renal disease Amount of TCS applied Extent of skin disease treated Frequency of application Length of treatment Potency of drug Use of occlusion It is not established whether catch up growth in children will occur when TCS are discontinued.
Local side effects of TCS Epidermal Atrophy - wrinkled skin with prominent vasculature, pseudoscars, striae or purpura Steroid dependence/rebound Glaucoma/cataracts t Increased susceptibility to bacterial, fungal and viral infections
Topical Steroids Benefits due to anti-inflammatory, immunosuppressive, vasoconstrictor and anti-proliferative actions Good response Slow response Atopic eczema, Cystic acne Allergic contact dermatitis, Alopecia areata Lichen simplex, Discoid LE Primary irritant dermatitis, Hypertrophied scars Seborrheic dermatitis, Keloids Psoriasis of face, Lichen planus Varicose eczema Psoriasis of palm, sole, elbow & knee
Topical Treatments Wet dermatitis - wet treatment dressings light creams Dry dermatitis - dry treatment ointments petrolatum Fetal vaccinia oils Eczema vaccinatum
Topical steroids are combined with antimicrobial agents for Impetigo Furunculosis Secondary infected dermatoses Napkin rash Otitis externa Intertriginous t i eruptions
Guidelines for topical steroids Penetration differs at different sites: High: axilla, groin, face, scalp, scrotum Medium: limbs, trunk Low: palm, sole, elbow, knee Occlusive dressing enhance absorption (10 fold) Absorption is greater in infants & Children
Guidelines for topical steroids Absorption depends on nature of lesion: High: atopic & exfoliative dermatitis Low: hyperkeratinized & plaque forming lesions More than 3 applications a day is not needed Choice of vehicle e is important t Lotions & creams: for exudative lesions Sprays & gels: for hairy regions Ointments: for chronic scaly lesions
Therapeutic principles Dose selection by trial & error; Needs frequent evaluation Single dose: No harm Few days therapy unlikely to be harmful Incidence of side effects related to duration of therapy Use is only palliative (except replacement therapy) Inter-current illness: Dose is doubled Abrupt cessation of prolonged high dose leads to adrenal insufficiency (contraindicated)
Dosage schedule Goal of therapy: To relieve pain or distressing symptom (e.g., rheumatoid arthritis): start with low dose To treat life threatening condition (e.g., pemphigus): initial dose must be high Prevention of HPA axis suppression: Single dose (morning) Alternate dose therapy (short lived glucocorticoids) Pulse therapy (higher glucocorticoid therapy)
Steroid withdrawal Longer the duration of therapy, slower the withdrawal Less than 1 week: withdrawal in few steps Rapid withdrawal: 50% reduction of dose every day Slow withdrawal: 2.5 5 mg prednisolone reduced at an interval of 2-3 days Longer period & high dose: Halve the dose weekly until 25 mg prednisolone or equivalent is reached Later reduce by about 1mg every 3-7 days. HPA axis recovery may take months or up to 2 years
Contraindications Infections Hypertension with CCF Psychosis Peptic ulcer Diabetes mellitus Osteoporosis Glaucoma Pregnancy : (prednisolone preferred)
Glucocorticoids antagonists Mitotane: structure similar to DDT, used in inoperable adrenal cancer Metyrapone: inhibit 11 β-hydroxylase Aminoglutethamide: inhibit conversion of cholesterol l to pregnolone, medical adrenelectomy Trilostane: inhibit conversion of pregnolone to progesterone; used in Cushing s s syndrome Ketoconazole: anti-fungal, inhibit CYP450 enzymes, inhibit steroid synthesis in ad.cortex and testis; used in Cushing s syndrome & Ca.prostate Mifepristone: glucocorticoid receptor antagonist; anti-progesterone, used in Cushing s syndrome
Factors to consider when prescribing topical corticosteroids t id 1. Type of preparation p (base and potency) Base can be ointment, cream, emulsion, gel or lotion Potency classified from group I (most potent) to VII (least potent) 2. Acute or chronic eczema 3. Age of child 4. Site to be treated 5. Extent of eczema 6. Method of application
TOPICAL IMMUNOSUPPRESANTS Newest pharmacological class for AD Introduced in this decade Direct immunosuppressive action in diseases with immunologic basis TACROLIMUS PIMECROLIMUS CYCLOSPORINE All act through calcineurin inhibition
Calcineurin inhibitors Two new agents: Tacrolimus (Protopic) 0.1% ointment Pimecrolimus (Elidel) 1.0% cream Derived from fungal polypeptides and Inhibit T- lymphocyte activation; Potent immunosuppressive if given systemically Demonstrated to be effective in childhood and adult AD Don t cause atrophy of the skin or other steroid side effects Slow acting anti-inflammatoryinflammatory Causes stinging and burn at initiation of therapy; slight increase in skin infections? Long-term safety not known
Pimecrolimus is different from corticosteroids Selective action on T cells and mast cells No effect on Langerhans /dendritic cells No induction of skin atrophy Much less permeation through skin
Summary HPA axis suppression does occur with the use of topical corticosteroids The adrenal suppression is not limited to the super potent t class of topical corticosteroids The type of vehicle may contribute to the extent of absorption of the active chemical moiety The suppression appears, in most cases, to be reversible upon cessation of drug usage