Dermocorticoids

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Introduction:

• Dermocorticoids (DC) were used in dermatology from the 1950s, their use was a therapeutic revolution in dermatology
• There are currently about twenty different molecules, which are classified according to their anti-inflammatory activity (from "low" to "very strong")
• Their use must, however, comply with rules that, in the vast majority of cases, prevent adverse effects

Biological actions:

• Vasoconstriction
• Anti-inflammatory effect: this is the most sought-after therapeutic effect, DC decreases the erythema and edema of any inflammatory cause, the targets are multiple: leukocytes, macrophages, chemical mediators…
• Antimitotic (antiproliferative) effect:

At the epidermal level: DCs have an atrophying effect

At the dermal level: the strongest DCs inhibit fibroblast growth and decrease collagen and elastic fiber synthesis

• Immunosuppressive effect: DCs decrease Langerhans cells and reduce their antigen presentation ability
• Tachyphylaxis (acute tolerance): it is revealed by resistance (tolerance) to treatment during prolonged and uninterrupted applications

Classification:

Activity / Level	Dci	Specialty
Very strong / IV	Betamethasone dipropionate Clobetasol propionate	Diprolene® Clotasol®
Forte / IV	Betamethasone dipropionate Hydrocortisone acponate Hydrocortisone butyrate Desonide	Diprosone® / Betasone® Efficort® Locoïd® Locatop®
Moderate / II	Desonide	Locapred®
Low / I	Hydrocortisone	Hydracort® / Cortiderm®

Pharmacokinetics:

• Skin bioavailability (skin penetration): depends on several factors:

DC-related factors: liposolubility and concentration, nature of excipient (penetration favoured by an ointment), presence of adjuvants (salicylic acid and urea)

Skin-related factors: altered skin (increased penetration), good hydration (better diffusion), anatomical site (depending on the thickness of the corneal layer), age (increased absorption in elderly subjects and premature), skin temperature (increased penetration with increased local heat)

Factors related to the mode of application: application surface, duration of contact, occlusion (multiplies skin absorption by 10)

• Reservoir effect: this is the accumulation of a DC in the corneal layer of the epidermis and then gradually released to the deep layers. It disappears when the corneal layer is pathological

How DCs are used:

• Activity level choice: depends on:

Type and surface of dermatosis: avoid very strong DCs over large areas

Lesion seat: Low to moderate DC on thin skin (face)

Patient age: Low to moderate DC in children

• Choice of galenic form: depends on the nature and seat of the lesions

Cream: has very broad indications

Pommade: used for dry, hyperplasic, keratosic dermatoses. Avoid in creases

Gel: useful for oozing lesions and creases

Lotion: suitable for hairregions

• Dosing rules: one application per day is usually sufficient, unless epidermal alteration (2x/d).

In case of prolonged treatment, avoid the sudden stop that exposes to the rebound effect (reappearance of symptoms), gradually reduce the power of the treatment, either by spacing the applications (1/2 then /3) or using a lower level DC

Indications:

It is a symptomatic and non-etiological treatment

• Corticoid alone:

Anti-inflammatory indications include allergic contact dermatitis (contact eczema), atopic dermatitis, irritation contact dermatitis, photosensitization (anti-inflammatory effect on sunburn), various pruritus (except for sunburn) scabies), others (localized plane lichen, insect bites, dyshidrosis)

For antiproliferative effects: lichenification (DC suppresses pruritus and decreases infiltration), psoriasis, hypertrophic and keloid scars

Other indications: seborrheic dermatitis, plaque scleroderma, pelade, vitiligo, bubble dermatitis

• In association:

With salicylic acid (Diprosalic®): for scaly dermatoses

With Daivonex® (derived from vitamin D): Daivobet®

With antifungals and antibiotics: this association is not justified

Contraindications:

Viral, bacterial, fungal and parasitic infectious dermatoses (except for eczema scabies), ulcerated dermatosis, facial dermatosis (acne, rosacea)

Effects:

• Local:

Atrophy: epidermal (reversible, fine epidermis in 'cigarette paper', face' ), dermal (definitive, delayed healing, pseudo-scarring, telangiectasies, bruising purpura

Skin rosaceiform dermatitis: induced acne, worsening of rosacea or perioral dermatitis

Skin infections: worsening of infection (herpes), infection secondary to dermatosis

Oculars: glaucoma, cataract / Hormonal: hypertriheals, sebaceous hyperplasia

Miscellaneous: infant gluteal granuloma (infant siege dermatosis), hypopigmentation, contact eczema allergic to CS or excipient

• Systemic: rare, are observed mainly in infants and children (application on large areas or under occlusion), the effects are the same as those observed after systemic corticosteroid therapy (brake axis hypothalamus-hypophysis-adrenals, cushingoid syndrome)