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
Dermoval® / ° Clotasol
Class 3 : Strong
Furoate de mométasone
Diprosone® / Betasone °
Class 2 : moderate
Class 1 : Low
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 anti–inflammatory :
- 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 anti–prolifératif :
- 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 :
5- hormonal effects :
- sebaceous hyperplasia
- generals : rares
6- uncontrolled because of dermatoses :
7- Divers :
- Infant gluteal granuloma
- Allergic Contact Eczema in DC or excipient
XI- AGAINST–INDICATIONS :
- Viral infectious dermatoses, bacterial, fungal and parasitic;
- Ulcerated dermatitis;
- Facial dermatosis.
Pr AS. CHEHAD