Topical Glucocorticosteroids
Introduction to Pediatric Topical Glucocorticosteroids
Key Principles
- Gold standard for treating inflammatory skin conditions in pediatrics
- Mechanism: Anti-inflammatory, antiproliferative, and vasoconstrictive effects
- Special considerations needed for pediatric population due to:
- Higher surface area to body mass ratio
- Thinner stratum corneum
- Increased percutaneous absorption
Basic Science
Molecular actions include:
- Inhibition of phospholipase A2
- Reduction of inflammatory mediators
- Decreased inflammatory cell migration
- Suppression of DNA synthesis and mitosis
Potency Classification
Class I (Super-potent)
- Clobetasol propionate 0.05%
- Limited use in pediatrics
- Reserved for severe, resistant conditions
- Maximum duration: 2 weeks
Class II-III (High Potency)
- Betamethasone dipropionate 0.05%
- Triamcinolone acetonide 0.5%
- Use with caution in children
- Short-term use only
Class IV-V (Medium Potency)
- Triamcinolone acetonide 0.1%
- Fluocinonide 0.05%
- Betamethasone valerate 0.1%
- Commonly used for moderate dermatoses
Class VI-VII (Low Potency)
- Hydrocortisone 1%, 2.5%
- Desonide 0.05%
- First-line agents for most pediatric conditions
- Safer for long-term use
Usage Guidelines
General Principles
- Selection Factors
- Patient age
- Anatomic location
- Surface area involved
- Severity of condition
- Vehicle selection (ointment, cream, lotion)
- Application Rules
- Fingertip unit (FTU) measurement
- Apply to affected areas only
- Avoid occlusive dressings unless specifically indicated
- Use lowest effective potency
Anatomical Considerations
- Face/Genitals
- Low potency only
- Short duration (5-7 days)
- Body Folds
- Low to medium potency
- Avoid occlusive effects
- Trunk/Extremities
- Can use medium potency if needed
- Monitor total surface area
Clinical Applications
Common Indications
- Atopic Dermatitis
- First-line: Class VI-VII for maintenance
- Flares: May require Class III-V
- Step-down approach recommended
- Contact Dermatitis
- Acute: Class IV-V for 5-7 days
- Chronic: Class VI-VII
- Seborrheic Dermatitis
- Class VI-VII only
- Short courses (3-5 days)
- Psoriasis
- Class III-V for plaques
- Class VI-VII for face/intertriginous areas
- Rotation strategy often needed
Treatment Strategies
- Acute Flares
- Higher potency, short duration
- Taper to lower potency
- Consider weekend-only therapy
- Maintenance
- Lowest effective potency
- Proactive treatment of common flare sites
- Integration with emollients
Adverse Effects & Monitoring
Local Adverse Effects
- Common
- Skin atrophy
- Striae
- Telangiectasia
- Hypopigmentation
- Acne/perioral dermatitis
- Prevention Strategies
- Use lowest effective potency
- Limited duration of use
- Regular monitoring
- Drug holidays when possible
Systemic Effects
- Risk Factors
- High-potency preparations
- Large surface area application
- Prolonged use
- Occlusion
- Potential Complications
- HPA axis suppression
- Growth retardation
- Cushing syndrome
- Increased infection risk
Monitoring Recommendations
- Regular clinical assessment (every 3-6 months)
- Growth monitoring in long-term use
- Morning cortisol if concerned about HPA suppression
- Documentation of total amounts used
- Photography for monitoring skin changes
