Dermocorticoïdes

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I- Introduction :

Topical steroids (DCTC) are steroids used by local topical route = ;

  • Mainly used for their anti-inflammatory and antiproliferative action.
  • Service classification activity level (from 1 low 4 very loud) estimated from the vasoconstriction test and comparative clinical trials.
  • The DCTC are symptomatic and not causal.
  • The prescription combines practical choice

– of style (Depending on the diagnosis, topography and age),

– the dosage,

– the pace of implementation (less than or equal to twice daily),

– of the amount required according to the surface to be treated.

  • Monitoring is necessary in chronic dermatosis, especially in children.

II- mechanisms d’action :

1- Receptor binding :

The DCTC through the cytoplasmic membrane by simple diffusion and bind to a specific receptor of the superfamily of steroid receptors.

2- The receiving DCTC complex crosses the nuclear membrane

3- Action on transcription :

  • Interaction with a nuclear receptor site
  • Modifying the expression of genes AEdit transcription.
  • Action on genes involved in proliferation : antiproliferative actions
  • Action on genes involved in the synthesis of cytokines (IL-1, TNFα…) : action immunosuppressive.
  • Also inhibit arachidonic acid release [forerunner of many molecules involved in the & rsquo; inflammation (leukotrienes)] : action anti- inflammatory.

III- properties Pharmacodynamic :

The DCTC have 3 main activities observed in therapy

1- Anti-inflammatory :

  • C & rsquo; therapeutic effect is the most sought DCTC.
  • Targets are multiple : leucocytes, macrophages and endogenous chemical mediators.
  • Vasoconstriction of dermal vessels to reduce erythema and edema regardless of the cause of inflammation.

2- Antimitotique – Antiproliférative :

  • Due to non-specific action on the cell cycle
  • Epidermis : atrophying effect and inhibit epidermal healing.
  • Dermis :  DCTC the strongest inhibit the growth of fibroblasts and decreased collagen synthesis.

3- Immunosuppressive :

  • The result of their anti-inflammatory action
  • but also & rsquo; fewer Langerhans cells and their antigen-presenting capacity.

IV- pharmacokinetics :

1- bioavailability :

a)- Nature from l’excipient :

  • ointments : consist of grasàeffet occlusifàaugmente excipient penetration ;
  • creams : less occlusive effect, but are most enjoyable job ;
  • The gels and lotion : penetrability < crème.

b)- additives :

  • keratolytic (Exp :  salicylic ac)  and moisturizers (Exp :  urea) increase penetration DCTC.

c)- Occlusion :

  • Increase penetration DCTC (up to X 10) ;
  • Obtained using plastic films ;
  • Used to treat thick hyperkeratotic lesions or ;
  • Increases the risk of infection.

d)- Dermatose at treat (state cutaneous) :

  • Penetration increases in skin diseases where the alteration of the epidermal barrier is important (GIVES, erythroderma ...)

e)- Topography :

  • The absorption is different from one point to another of integument ;
  • Important in the folds
  • Less in areas where the skin layer is thick (palms, plants)

f)- Age :

  • Penetration is highest among the preterm infants and in the elderly ;
  • Absorption is important in children because of a surface / high weight.

2- reservoir effect :

  • There is an accumulation of the DC level of the stratum corneum.
  • She is responsible for a gradual release
  • What justifies a single daily application.

3- Tachyphylaxie :

  • c & rsquo; is & rsquo; & rsquo appearance, resistance to treatment during prolonged and uninterrupted application.

V- Classification :

On distingue 4 power levels. Examples of DCTC available in Algeria :

 

Denomination commune international

Last name commercial

Class 4 : Very strong

Clobétasol propionate

Bétaméthasone dipropionate

Dermoval® / ° Clotasol

Diprolène®

Class 3 : Strong

Bétaméthasone dipropionate

Furoate de mométasone

Hydrocortisone acéponate

Hydrocortisone butyrate

Diprosone® / Betasone °

Cortisaf®

Locoïd®

Efficort°

Class 2 : moderate

desonide

Locapred®

Class 1 : Low

Hydrocortisone

Hydracort® / cortiderm °

 

WE- modalities of use :

1- Choice from l’activity of DCTC :

a)- Dermatose at treat :

  • The class DCTC 4 : resistant lesions (Exp :psoriasis)
  • chronic dermatosis :
  • Start with the strongest DCTC, able to control symptoms.
  • Then adjusts the strength of the DC according to the response.

b)- The surface at treat and the seat :

  • The classes 4 and 3 be avoided on the face and folds.

c)- Age of patient :

  • The classes 4 and 3 be avoided in children.

2- Choice from l’excipient :

  • Ointment : dry dermatoses, keratosic.
  • Crème : very broad indications : oozing lesions and in plis. lotions or gels are is suitable for hairy areas.

3- pace and technique d’application :

  • One application per day is usually sufficient. In some erosive dermatoses, two applications per day may be required initially (disappearance of the & rsquo; reservoir effect).
  • A phasing, is often achieved either by space applications, either by using a lower level DCTC.
  • The occlusion is restricted to thick lesions and / or hyperkeratotic, resistant and limited surface.
  • The dose should not be exceeded is d & rsquo; about 30 g / week of class finished product 3 Maintenance in adults.

4- Surveillance of treatment :

  • Quantifying the number of tubes used
  • Monitoring the growth curve in children (TRT-going)

VII- Indications :

The DCTC are symptomatic and not causal.

1- For their effect antiinflammatory :

  • contact dermatitis associated with allergen avoidance ;
  • Atopic dermatitis. This is a long-term treatment,  need supervision.
  • other eczema : varicose eczema, nummulaire, dysidrose,
  • Photosensibilisations :   the DCTC have an anti-inflammatory effect on sunburn. They can be useful for other Photodermatoses.
  • Lichen localized plane / psoriasis localized ...
  • Insect bites.

2- For their effect antiprolifératif :

  • Psoriasis :  They may be associated with the & rsquo; salicylic acid in highly hyperkeratotic lesions.
  • lichenification : DCTC removes the itching and decreases the infiltration. It is best to use a level of DC 4.

3- For their effect immunosuppressive :

  • Pemphigoïde bulleuse : use d & rsquo; a class DCTC 4.

VIII- Injections intralésionnelles :

  • Indication :
  • Some localized lesions after potent topical failure
  • Hypertrophic scars and keloids
  • Side effects : idem, but the atrophy may be imposed.

IX- corticosteroids in association :

  • L & rsquo; association & rsquo; a DCTC to & rsquo; salicylic acid increases penetration and & rsquo; keratolytic effect. It is interesting for squamous dermatoses.
  • The associations in a single preparation & rsquo; a DCTC and & rsquo; an anti-infective (antiseptic, antibiotic, antifungal) never justifiéesàrisque awareness.

X- Effects secondary dermocorticoids :

1- Atrophy :

  • Epidermal, reversible : epidermal thinning in "cigarette paper", fragility at the slightest trauma
  • Dermal : delayed healing, telangiectasia, purpura Ecchymotic, stretch Marks (non-reversible)

2- Dermatitis of the face :

  • acne induced
  • Worsening of rosacea
  • rosacea cortisone
  • perioral dermatitis

3- skin infections :

  • Worsening infection (herpes +++, dermatophytoses, gale…) Secondary infection of skin disease (infrequent)

4- ocular side effects :

  • Glaucoma
  • Cataract

5- hormonal effects :

  • Hypertrichose
  • sebaceous hyperplasia
  • generals : rares

6- uncontrolled because of dermatoses :

  • rebound
  • Addiction

7- Divers :

  • Hypopigmentation
  • Infant gluteal granuloma
  • Allergic Contact Eczema in DC or excipient

XI- AGAINSTINDICATIONS :

  • Viral infectious dermatoses, bacterial, fungal and parasitic;
  • Ulcerated dermatitis;
  • Facial dermatosis.

Pr AS. CHEHAD