EDITDRIALS

Topical corticosteroids
The most exciting chapter in the relevant than the matter of safety. enough to modify the local immune
history of dermatological therapy Great advances inevitably create response to cutaneous infections,
began in 1952 with the discovery new problems. The topical corticos¬ especially superficial fungous and
that hydrocortisone, in contrast to teroids brought many new problems Candida albicans infections and
its progenitor cortisone, exhibited with them, both local and systemic. scabies infestation. The symptoms
an anti-inflammatory effect when A most important local side effect and appearance of these common
applied in ointment form to in- of topical corticosteroid therapy is diseases may be so modified that
flamed skin. Only those who have atrophy of the skin. When a potent accurate diagnosis becomes ex¬
faced the frustrations of local ther¬ corticosteroid has been applied in- tremely difficult or impossible even
apy in the precorticosteroid era can tensively for several months, and for the most expert, while the pa¬
fully realize what a giant step for¬ especially when plastic film occlu¬ tient continues to suffer nagging
ward hydrocortisone represented. sion of the ointment has been used discomfort which is all too often
But it had drawbacks. It was ex¬ to enhance penetration of the epi¬ labelled functional in nature. De¬
pensive and its anti-inflammatory dermal barrier, the skin gradually pressed local immunity also makes
effect was woefully weak by today's becomes extremely thin, fragile and the bacterial infections folliculitis
standards. The fear of dangerous almost transparent. This is due to and furunculosis a continuing source
side effects, associated in physicians' the inhibitory effect of the corti¬ of trouble in corticosteroid-treated
minds with the then new and mys- costeroid on collagen synthesis by patients, especially where plastic
terious systemic corticosteroid ther¬ the dermal fibroblast.2 Networks of film occlusion is used and particu¬
apy, kept most non-dermatologists telangiectatic capillaries and venuleslarly in hospital where virulent sta-
from using it. The topical corticos¬ become apparent giving a grotesque phylococci abound. Occasionally in
teroid revolution had to wait for a appearance to the skin. Many of female patients topical corticoster¬
better product. these vessels rupture producing oids will stimulate vigorous growth
The modern era began in earnest large areas of ecchymosis. The tis- of facial hair. They may cause rosa-
in 1960 with the introduction of the sue-paper thin skin tears from the cea to flare. 4'5
fluorinated corticosteroids triam- slightest trauma and heals with a Finally, the topical corticosteroid
cinolone, flurandrenolone and flum- disfiguring scar. The facial skin of medication itself may cause un¬
ethasone, each of which was four to females is particularly susceptible expected trouble. Parabens (esters
six times as potent as hydrocorti¬ to atrophy and may be further dis- of p-hydroxybenzoic acid), used to
sone. In 1962 a third generation of figured by generalized,
a florid, preserve the ointment base, may
topical corticosteroids, betametha- erythematous appearance which is produce allergic sensitization in a
sone 17-valerate, fluocinolone and cosmetically disastrous.8 Striae significant number of patients.
beclamethasone, with 10 to 20 times atrophicae develop on the trunk Iodochlorhydroxyquin (Vioform®),
the potency of hydrocortisone, be¬ and limb areas of many patients chiefly an anti-candida agent, neo¬
came available and has subsequently from fibroblast inhibition and the mycin and other antibiotics are fre¬
dominated the market-place.1 In this same mechanism causes topical cor¬ quently added to corticosteroid oint-
issue of the Journal (page 33) Stewart ticosteroids to impair healing of ments and may produce a sensitivity
and his colleagues indicate that the ulcers. These unwanted effects, reaction which is of low intensity
search for new compounds proceeds serious as they are, are outranked and difficult to detect.7 Appropriate
relentlessly but it is prompted by in importance by changes produced patch testing will reveal the true
commercial competition rather than in local immunity. cause of treatment failure in such
by inadequacy in presently available The anti-inflammatory effect of cases.
medications. The matter of anti- the second and third generation The possibility that a significant
inflammatory potency is now less topical corticosteroids is powerful amount of a corticosteroid might be
C.M.A. JOURNAL/JANUARY 6, 1973/VOL. 108 11

108 13 . Proc R era.atopic. In today's has proved to give little cause for The wise physician will exercise world the old saying that the pa- concern even when plastic film oc. FEIWEL M: Pituitary-adrenal function after Their sole action is to suppress in. p. potency and duration of treatment areas because the widely-used cream in infants to minimize this risk. He will begin 1. Dr.M. 1969 They do not cure any skin disease. 1973/VOL. 8. 1967 physician must discover the cause plying the medication.' In infants. Br J Clin Pract 25: 421. Lancet II: 1059.8 ly familiar. He will give his occlusive topical therapy with beta- flammation. Oxford and treatment of dermatitis of all kinds the dermatitis responds. never dies. it is re. JOURNAL/JANUARY 6. ditions of the 1930s. as always. STARR PJ. Pharmacology 22: 745. of the Beveridge report in the and health insurance. These medications can tenance. 1969 Thirty years onward It is salutary to be reminded of the author the recognition which it sation of hostilities. He will suppress bacterial and fun. Care must be taken to limit the for all but moist or intertriginous 450 Central Avenue. if his patient's eruption does ES. He will avoid taneous aspects of rosacea. effects. hazards and side Therefore. country to the brave new world planners. penetrates poorly. these examples though it has not attained for its which would be ours with the ces. with commendable humi- following its local application to the with dermatitis fail to benefit from lity. EBLING FJG: in Textbook of Derma- tology. activities and contacts to avoid and oid preparations. Lancet I: short time he will seek expert help 485. corticosteroids in rosacea. for the treatment of special areas 4. MuNRo DD. and children with eczema. Looking back. survival. BARNET r nosis and precise management re. In view of current developments were in uniform and their opinions men for the profession needed to we were naive to have predicted and their professional futures were know whether their proposals en. Taylor's nostal. with an ease and reliability un. EBLING FJG. He will use the ointment W. when we visualized administration the CMA Committee of Seven dorsation was forthcoming and that by representative non-political com- which had participated in an endless relationships with federal authorities missions. MACDONALD A: Topical corticoster- of the eruption and remove it. aration. Finally.Effect of potent topical steroids main the kingpins of successful not respond within a reasonably on plasma-cortisol levels of infants dermatological therapy. PACE. and may impair the stress response. JAMES VHT. M. but just goes on areas. He will pre. would "materially decrease" by pro- civilian colleagues who undertook sociation. edited by RooK A. COOPER DR. 1969 5. January 18. gous infection when present with a 6. Ont. tell him what 7. tient with dermatitis "never gets clusion has been used over large pical corticosteroid.D. order it applied generously 2. were to be eral Council at its first Special United Kingdom. In the adult this problem faulty management by the physician. better. Br Med J 11: 297. SNEDDON I: Adverse effect of topical ern dermatological therapy. then change Edinburh. The House of available to justify the wartime ef- Meeting. where he has failed. The Report on Social markable that such concentrated roneous than the projections of the Security for Canada by Leonard C. however. I: 671. . To achieve cure. medical statesmen who constituted deserves. London 14. Malcolm G. But other medications for routine use. Social measures. 3. seborrheic and to a reduced concentration for main. PRICE CH: Corticosteroid-collagen interaction in non-specific. JAMES VHT. the patient detailed instructions for ap. They are the backbone of mod. that the cost of curative services uppermost in the minds of their joyed the backing of the whole As. accurate diag. MACDONALD A: Oculocu- dreamed of in the precorticosteroid such as the hands. Blackwell-Davis. 1969. Our concepts of the costs series of meetings and discussions were indeed promising for a cooper. counsel him regarding his stresses. 1970. This Commons' Special Committee on fort and to avoid the dreadful con- country was involved in a war of Social Security was about to com. ventive services in public health.A. vol I. viding primary attention to pre- to represent them. propriate. involved were those of economic on health insurance as it was then ative effort. materially aided by demonstrates clearly that this en. a great many members mence its hearings and the spokes. it was really of the stature including unemployment insurance the membership of the CMA Gen. methasone-17-valerate. 1969 must be recognized that topical cor. E. Br Med J these medications are not panaceas. KANFER I. The Heagerty Committee had gic article in this issue (page 86) We were also politically innocent done its work. systemic antibiotic. 1943. He will use plastic film vitro: fibril formation from collagen suppress inflammation of the skin occlusion on resistant lesions and solutions. of hindsight should not detract from C. has an undesirable drying effect and References While the list of undesirable ef. using corticosteroids combined with Soc Med 62: 9.absorbed by the systemic circulation A surprising number of patients realizing. WIL- ticosteroids have revolutionized the a minimum of three times daily until KINSON D. great care when he prescribes a to. However. 1971 8. FEIWEL M. Today's Drugs: Topical corticoster- fects is admittedly impressive it treatment with the most potent prep. amateurs but they were no more er- recognized. contact. that the ways of skin are devi- skin worried investigators from the topical corticosteroids because of ous and that others may succeed beginning. oids. systemic scribe one of the third generation scratching forever" is no longer ap- absorption can be a real problem products with which he is thorough. attention was being given in this Treasury Board and other financial Marsh had been submitted and al.