Kenalog, Triacet) Clocortolone pivalate1 (Cloderm) Flumethasone pivalate1 (Locorten) 0.05% 0.05% 0.025% 0.05% 0.05% 0.1% 0.025% 0.05% 0.05% 0.1% 0.25% 0.5% 0.2% 0.05% 0.1% 0.05% 0.05% 0.05% 0.05%
Fluticasone propionate (Cutivate) Desonide (Desowen) Halcinonide1 (Halog) Desoximetasone1 (Topicort L.P.) Flurandrenolide1 (Cordran) Triamcinolone acetonide1 Fluocinolone acetonide1
Betamethasone dipropionate1 (Diprosone, Maxivate) Amcinonide1 (Cyclocort) Desoximetasone1 (Topicort) Triamcinolone acetonide1 Fluocinolone acetonide1 (Synalar-HP) Diflorasone diacetate1 (Florone, Maxiflor) Halcinonide1 (Halog) 1Fluorinated steroids.
Experimental studies on the percutaneous absorption of hydro-cortisone fail to reveal a significant increase in absorption when applied on a repetitive basis and a single daily application may be effective in most conditions. Ointment bases tend to give better activity to the corticosteroid than do cream or lotion vehicles. Increasing the concentration of a corticosteroid increases the penetration but not proportionately. For example, approximately 1% of a 0.25% hydrocortisone solution is absorbed from the forearm. A tenfold increase in concentration causes only a fourfold increase in absorption. Solubility of the corticosteroid in the vehicle is a significant determinant of the percutaneous absorption of a topical steroid. Marked increases in efficacy are noted when optimized vehicles are used, as demonstrated by newer formulations of betamethasone dipropionate and diflorasone diacetate.
Table 61–4 groups topical corticosteroid formulations according to approximate relative efficacy. Table 61–5 lists major dermatologic diseases in order of their responsiveness to these drugs.
TABLE 61–5 Dermatologic disorders responsive to topical corticosteroids ranked in order of sensitivity.
Later phase of allergic contact dermatitis
Later phase of irritant dermatitis
Psoriasis, especially of genitalia and face
Psoriasis of palms and soles
Least responsive: Intralesional injection required
In the first group of diseases, lowto medium-efficacy corticosteroid preparations often produce clinical remission. In the second group, it is often necessary to use high-efficacy preparations, occlusion therapy, or both. Once a remission has been achieved, every effort should be made to maintain the improvement with a low-efficacy corticosteroid.
The limited penetration of topical corticosteroids can be overcome in certain clinical circumstances by the intralesional injection of relatively insoluble corticosteroids, eg, triamcinolone acetonide, triamcinolone diacetate, triamcinolone hexacetonide, and betamethasone acetate-phosphate. When these agents are injected into the lesion, measurable amounts remain in place and are gradually released for 3–4 weeks. This form of therapy is often effective for the lesions listed in Table 61–5 that are generally unresponsive to topical corticosteroids. The dosage of the triamcinolone salts should be limited to 1 mg per treatment site, ie, 0.1 mL of 10 mg/mL suspension, to decrease the incidence of local atrophy (see below).