It’s time to address some of the myths around corticosteroids. What’s the latest advice regarding the risks and appropriate use?
It is common for topical corticosteroids to be prescribed to treat inflammatory skin conditions, such as eczema, rash, atopic dermatitis and psoriasis. When used appropriately, topical corticosteroids are considered both safe and effective.
However, despite the fact topical corticosteroids are the most widely used and effective drugs in dermatology, many people are afraid to use them because of common misconceptions and misunderstandings associated with their use.
While community pharmacists are in an ideal position to offer advice on how to best use corticosteroids to achieve the optimal treatment outcome, correct advice is often reliant on individual pharmacists’ own knowledge, beliefs and attitudes.
Attitudes towards topical corticosteroid use
Many studies have shown that a large proportion of pharmacists and GPs continue to give outdated advice in regards to corticosteroid use and safety. However, without clear and consistent advice, patients’ fears (steroid phobia) can be exacerbated, leading to poor adherence and negative treatment outcomes.
A study by Saxon Smith et al (2016) into Australian pharmacists’ knowledge about the use of topical corticosteroids in atopic dermatitis showed a major shift in advice-giving pre and post continuing professional development (CPD) education.
Prior to the CPD conference, 54% of the pharmacists involved admitted they would instruct patients to use topical corticosteroids sparingly. Post-education, this dropped to 8%.
Similarly, before the education only 27% of pharmacists would advise patients to apply topical corticosteroids until the eczema is clear. Post-education, this increased to 92%.
This shows substantial knowledge gaps, as well as inconsistent advice about the use and safety profile of topical corticosteroids.
A 2017 UK study into pharmacists’ knowledge and advice-giving behaviour regarding topical corticosteroids highlighted similar issues. While pharmacists showed a good knowledge of most issues relating to safety, only 54% of the pharmacists gave the correct answer in regards to skin thinning (atrophy).
Just under half of the respondents believed skin thinning is common when topical corticosteroids are used, which isn’t true.
More than 20% also claimed topical corticosteroids should only be used to treat the worst affected areas of skin in children. Whereas, the correct advice is that cream can be applied to all affected areas.
Additionally, the study revealed that while the pharmacists consistently counselled patients about the duration, frequency and quantity (finger-tip unit) of topical corticosteroids, they rarely provided counselling on the potency of the different formulations.
Similarly, a study into Australian GPs’ perception of the safety of topical corticosteroids in the treatment of paediatric atopic dermatitis showed similar beliefs and advice‑giving behaviour.
Of the 257 GPs surveyed, more than a third (40.7%) of them advised parents to apply treatment for two weeks or less. Almost half (47.7%) advised parents to use topical corticosteroids sparingly, using the smallest amount, and almost one-third (30.2%) named skin atrophy as the most common side effect.
Unfounded fears and calls for consistent advice
For several years there have been calls for consistent advice on topical corticosteroids—from dermatologists and pharmacists alike. In 2017 the Australasian College of Dermatologists (ACD) released a position statement on the use of topical corticosteroids in paediatric eczema, which was the basis of most of the safety concerns.
The advice from the ACD is that “topical corticosteroids remain the mainstay of the management of active atopic eczema in combination with the regular use of emollients.” And that “the safety profile of topical corticosteroids remains robust when used appropriately.”
The term ‘use sparingly’ should not be used, as this is misleading and can invoke fear in patients, who then often end up not using their cream at all. Yet, despite the advice from the ACD—which states a sufficient amount of cream should be applied to cover the entire of the affected area—people are still being told to use topical corticosteroids sparingly.
A 2016 poll published on the AJP website asked pharmacists what advice they give out to patients regarding the use of topical corticosteroids. While more than half (55%) of respondents said they remove the term ‘use sparingly’ from labels and offer advice on using fingertip units, almost 20% of pharmacists still advised people to ‘use sparingly’.
Debbie Rigby, consultant clinical pharmacist, tells the AJP, “It can be challenging for pharmacists if ‘apply sparingly’ is written on the script; although we always have a duty of care to the patient to provide the best possible advice.”
Clinical dermatologist Professor Gayle Fischer says, “Conflicting advice relating to topical corticosteroids is extremely destructive and yet it’s widespread. I still hear the term ‘use sparingly’ every day. It is still being put on scripts and it’s still what pharmacists and some GPs firmly believe.
“When you have a script that has come from a dermatologist to treat a chronic, ongoing condition and you have a pharmacist giving different information to what’s on the script it’s incredibly frustrating.
“All skin conditions are chronic and so they all need continuing treatment but when a pharmacist says to their patient ‘use this very sparingly and for no more than 10 days’, it’s as sensible as telling someone with diabetes to stop using their insulin after 10 days when their blood sugar is back in range.”
Ms Rigby says, “I do think the message has got out to a lot of pharmacists about avoiding use of the words ‘apply sparingly’ on labels and not warning patients about overuse causing skin atrophy. However, old myths and beliefs do persist—among patients, doctors and pharmacists. I think pharmacists need to be proactive in reassuring patients and parents around these misconceptions whenever we dispense topical steroids, and sell OTC products.”
What should you be telling patients about corticosteroids?
Professor Fischer says pharmacists need to be positive about topical corticosteroids. “These drugs are really safe and highly effective. As such, pharmacists need to reassure patients that these products are, like all medications, safe when used as intended.
“You might ask ‘how has your doctor told you to use this?’ and then reinforce the information. For example, you might advise the patient to use as directed until their skin is completely better, not just until the itching has reduced. You might also ask if their doctor has requested that they make a follow-up appointment and, if so, encourage them to do this—particularly if they don’t see an improvement.”
The ACD advises most topical corticosteroids can be applied once or twice daily to all areas of inflamed skin until the condition has cleared. There is no need for intervals without therapy if the skin is still inflamed. There is also no need to use sparingly. Instead, an ample amount of the formula should be used to completely cover the affected area.
Key information pharmacists can provide includes:
- Which topical corticosteroid to apply (i.e. which formulation and what potency);
- Where on the body to apply it (particularly if the patient is using more than one product);
- How much to apply (finger-tip units);
- How often to apply (i.e. frequency).
To optimise patient outcome it’s important to select the appropriate formulation and potency. Pharmacists should be familiar with which formulation to use on different parts of the body.
- Creams — good for large areas of the body and intertriginous areas, such as the armpit, inner elbow, between fingers and toes, as well as the genital region.
- Lotions and gels — useful for use on hair-bearing regions of the body, such as the scalp.
- Ointments — good for areas where there is thick skin or scale and severe dryness. Should not be applied on areas of the body with hair.
“It is also important for pharmacists to be aware of the relative potencies. For example, Advantan really is a very innocuous topical steroid; it’s unlikely a person will get any side effects from it and yet people have been told it’s dangerous,” says Prof Fischer.
Furthermore, several studies have noted patients incorrectly grade the potency of their formulations, which can have a bearing on adherence. A questionnaire-based study of 200 dermatology outpatients with atopic eczema showed 72.5% of people worried about using topical corticosteroids on their own or their child’s skin. While the most commonly used topical corticosteroid was hydrocortisone, 31% of patients who used this preparation incorrectly classified it as either strong, very strong or did not know the potency.
“The Australian Medicines Handbook (AMH) has some good information on the relative potency of topical corticosteroids and a useful patient information leaflet on fingertip units that pharmacists can print off and discuss with patients,” says Ms Rigby.
She adds, “Sometimes I see a mismatch between the quantities prescribed and the appropriate amount to use over the body area each month. A table in the AMH also provides suggested weekly quantities over different application areas. For example, 30–40g of product is required for a single application to the whole body of an adult.”
Smith SD, Lee A, Blaszczynski A, Fischer G. Pharmacists’ knowledge about use of topical corticosteroids in atopic dermatitis: Pre and post continuing professional development education. Australas J Dermatol. 2016 Aug; 57(3):199-204.
Smith SD, Harris V, Lee A, Blaszczynski A, Fischer G. General practitioners’ knowledge about use of topical corticosteroids in paediatric atopic dermatitis in Australia. Australian Family Physician. 2017 May;46(5):335-40.
Gabros S, Nessel TA, Zito PM. Topical Corticosteroids. [Updated 2020 Sep 29]. In: StatPearls. Accessed online Jan 2021. Via: https://www.ncbi.nlm.nih.gov/books/NBK532940/
Ponnambath N, Pynn E. How to reassure patients with topical steroid phobia. Prescribing in Practice. Prescriber. 2014 March;25(5):21-3.
Charman CR, Morris AD, Williams HC. Topical corticosteroid phobia in patients with atopic eczema. Br J Dermatol. 2000 May;142(5):931-6.