Dermocorticoids

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I- Introduction:

Dermocorticoids (DCTCs) are steroids used locally – topical;

• Mostly used for their anti-inflammatory and antiprolifeferative actions.
• Classification based on the level of activity (from 1 low to 4 very strong) estimated based on vasoconstriction and comparative therapeutic trials.
• DCTCs are a symptomatic treatment, not an etiological one.
• Prescription in practice combines choice

– class (function of diagnosis, topography and age),

– galenic,

– the rate of application (less than or equal to twice a day),

– the amount needed depending on the surface to be treated.

• Follow-up is necessary in cases of chronic dermatitis, especially in children.

II- Mechanisms of action:

1- Link to receivers:

DCTCs pass through the cytoplasmic membrane by simple diffusion and bind to a specific receptor of the steroid receptor superfamily.

2- The receptor complex-DCTC passes through the nuclear membrane

3- Action on the transcript:

• Interaction with a nuclear catcher site
• Change in gene expression to transcription modification.

• Action on genes intervening on proliferation: anti-proliferation action
• Action on genes involved in cytokine synthesis (IL-1, TNF…): immunosuppressive action.
• Also inhibit the release of arachidonic acid: an[précurseur   de nombreuses molécules  impliquées  dans l’inflammation (leucotriènes)]ti-inflammatory action.

III- Pharmacodynamic properties:

DCTCs have 3 main activities observed in therapeutics

1- Anti-inflammatory:

• This is the most sought-after therapeutic effect of DCTCs.
• The targets are multiple: leukocytes, macrophages and endogenous chemical mediators.
• Vasoconstriction of dermal vessels to decrease erythema and edema regardless of the cause of inflammation.

2- Antimitotic – Antiprolifeferative:

• Due to a non-specific action on the cell cycle

• Epidermis: atrophying effect and inhibiting epidermal healing.
• Derme: The strongest DCTCs inhibit the growth of fibroblasts and decrease collagen synthesis.

3- Immunosuppressive:

• Result of their anti-inflammatory action
• but also a decrease in the number of Langerhans cells and their ability to present antigens.

IV- Pharmacokinetics:

1- Bioavailability:

a)- Nature of the excipient:

• Pommades: made up of fat excipient to occlusive effect to increase penetration;
• Creams: less occlusive effect, but are more pleasant use;
• Gels and lotion: penetrating power< crème.></ crème.>

b)- Additives:

• Keratolytics (Exp: Ac salicylic) and moisturizers (Exp: urea) increase the penetration of DCTC.

c)– Occlusion:

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

d)- Dermatosis to be treated (skin condition):

• The penetration increases in dermatoses where the alteration of the epidermal barrier is important (DA, erythrodermia…)

e)– Topography:

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

(f)– Age:

• Penetration is high in preterm infants and elderly people;
• Absorption is important in children due to a high surface-to-weight ratio.

2- Tank effect:

• There is an accumulation of DCs in the corneal layer.
• It is responsible for a gradual release
• This justifies a single daily application.

3- Tachyphylaxis:

• it is the appearance of resistance to treatment during prolonged and uninterrupted applications.

V- Classification:

There are four levels of power. Examples of DCCCs available in Algeria:

	International common name	Trade name
Class 4: Very strong	Clobétasol propionate Betamethasone dipropionate	Dermoval®/Clotasol Diprolene®
Class 3: Forte	Betamethasone dipropionate Mometasone furoate Hydrocortisone aceponate Hydrocortisone butyrate	Diprosone® /Betasone Cortisaf® Locoïd® Efficort
Class 2: Moderate	Desonide	Locapred®
Class 1: Low	Hydrocortisone	Hydracort®/ cortiderm

 

VI- Terms of use:

1- Choice of DCTC activity:

a)- Dermatosis to be treated:

• DCTC Class 4: Resistant Lesions (Exp :psoriasis)
• Chronic dermatosis:

• Start with the strongest DCTC, able to control symptoms.
• Then adapts the strength of the DC according to the response.

b)- The surface to be treated and the seat:

• Classes 4 and 3 should be avoided on the face and creases.

c)– Patient age:

• Classes 4 and 3 should be avoided in children.

2- Choice of the excipient:

• Pommade: dry dermatoses, keratosic.
• Cream: very broad indications: oozing lesions and in the creases.

3- Rhythm and application technique:

• One app a day is usually enough. In some erosive dermatoses, two applications per day may initially be needed (disappearance of the tank effect).
• A gradual shutdown is often achieved either by spacing applications or by using a lower level DCTC.
• Occlusion is reserved for thick and/or hyperkeratosic, resistant and limited-surface lesions.
• The dose not to be exceeded is about 30 g/week of class 3 finished product in maintenance in an adult.

4- Monitoring treatment:

• Quantification of the number of tubes used
• Tracking the growth curve in children (long-term TRT)

VII- Indications:

DCTCs are a symptomatic and non-etiological treatment.

1- For their anti–inflammatory effect:

• Contact eczema associated with allergen expulsion;
• Atopic dermatitis.  It is a long-term treatment, requiring monitoring.
• Other eczemas: varicose eczema, nummular, dysidrosis,
• Photosensitizations: DCTCs have an anti-inflammatory effect on sunburn.  They can be useful for other photodermatosis.
• Lichen localized plane / localized psoriasis …
• Insect bites.

2- For their anti-proliferative effect:

• Psoriasis: They may be associated with salicylic acid in very hyperkeratic lesions.
• Lichenification: THE DCTC removes pruritus and decreases infiltration. It is best to use a Level 4 DC.

3- For their immunosuppressive effect:

• Pemphigoid bubble: use of a Class 4 DCTC.

VIII- Intralesional injections:

• Indication:

• Some localized lesions after failure of powerful topicals
• Hypertrophic scars and keloids

• Side effects: Ditto, but atrophy may be pronounced.

IX- Corticosteroids in combination:

• The combination of a DCTC with salicylic acid increases penetration and the keratolytic effect. It is interesting for scaly dermatoses.
• Associations in the same preparation of a DCTC and an anti-infective (antiseptic, antibiotic, antifungal) are never justified at any awareness risk.

X- Side effects of dermocorticoids:

1- Atrophy:

• Epidermal, reversible: epidermal thinning in "cigarette paper", fragility at the slightest trauma
• Dermal: delayed healing, telangiectasies, purpura- ecchymotic, stretch marks (not reversible)

2- Facial dermatitis:

• Acne induced
• Worsening rosacea
• Rosacea cortisonée
• Peroral dermatitis

3- Skin infections:

• Aggravation of an infection (herpes, dermatophytoses, scabies…) Secondary infection of dermatosis (infrequent)

4- Eye side effects:

• Glaucoma
• Cataract

5- Hormonal effects:

• Hypertrichosis
• Sebaceous hyperplasia
• Generals: rare

6- Uncontrolled cause dermatoses:

• Rebound phenomenon
• Dependence

7- Various:

• Hypopigmentation
• Infant gluteal granuloma
• Allergic contact eczema to DC or excipient

XI-CONTRAINDICATIONS:

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

Professor AS. CHEHAD