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Topical Corticosteroid Side Effects
dr. MOH. IFNUDIN, SpKK.
dr. MOH. IFNUDIN, SpKK.
INTRODUCTION Since the introduction of topical hydrocortisone in the early 50's, topical corticosteroids have a place of paramount importance in the field of dermatology because of his usefulness is so broad. Topical corticosteroids are anti-inflammatory sidiaan reliable, but it also has the effect antipoliferatif, vasokonstriktif and imunosupresif.1, 2,3,4 This preparation has been widely used worldwide in four decades. Topical corticosteroids is one of the most commonly prescribed drug in the treatment of disorders kulit.3 Approximately 50% of prescriptions written by a dermatologist is a corticosteroid topikal.5 Along with that, pharmaceutical companies vying to produce preparations with a stronger potential, including through modification of the molecular structure of hydrocortisone or form sintetiknya by halogenated, methylation, acetylation, esterification, and sebagainya.1 such a rich variety of topical corticosteroid that there is, then do the classification based on the potential start of a very strong or very potent to mild or lemah.1 potential, 3.5 In addition to the molecular structure, several factors such as concentration, vehikulum and penetration may affect the clinical effectiveness of a corticosteroid topikal.3, 5 Too bad the story behind the success of various topical corticosteroids, the emergence of problems that may arise from effects that are not expected. Risks that accompany the use of a topical corticosteroid is parallel with the power terapeutiknya.1, 4.5 more the potential of a preparation, the easier or the greater the possibility for the emergence of securities merugikan.1, 2.4 Even the latest generation which has shown increased efficacy, still not entirely free from the effects samping.2 SIDE EFFECTS topical corticosteroids Today so many topical corticosteroid preparations on the market, both the "pure" or combination with other materials such as antifungal, antibacterial and even recently identified the existence of products aimed at the problem of beauty, containing corticosteroids. While the society is so easy to obtain drugs freely. These things may be one factor that causes more and more encountered patients who showed clinical symptom picture or side effects of topical corticosteroids. While other factors which may contribute to the provision of prescription from the doctors themselves are less precise. Therefore, in addition to knowledge about the skin disorder which is responsive to corticosteroids, the type, potency, and how to work kostikosteroid topical, perlua well known and wary about the side effects that can be generated. Adverse effects often arise because of inappropriate use. It is noteworthy that the efficacy and possible side effects depend on: 1. Type of corticosteroids and vehikulum 2. How to use: frequency, duration and usage of the occlusion 3. The circumstances and extent of lesions 4. Patient factors: age, location of lesion. The emergence of these impacts are not expected to increase, among others, if topical corticosteroids are used on the skin is thin or damaged, the children or parents, or bandage adanay oklusi.3 Side effects of topical corticosteroids can be divided into local and systemic effects, where local effects jaih more frequently obtained. SIDE EFFECTS OF LOCAL Various skin lesions as a side effect of topical corticosteroids vary with the effects arising from the utilization of oral because such stocks exert its action on the application of high dalamkonsentrasi. Pemakaina topical corticosteroids will cause the stocks are on the skin in high concentrations so that various local effects that vary can occur. Skin atrophy and striae Is the most common side effects encountered, where the skin looks thin, shiny and almost always visible telangiektasi-striae.1, 3,4,5 This happens, on the use of a longer and more easily arise in a region that many sweaty, covered or high penetration like armpits, groin or intertriginous areas and wajah.3, 5 Basically can arise anywhere that long to use corticosteroids kuat.4 potential Biasanaya atrophy began to occur after the use minggu.3 3-4, 5 Thinning of the epidermis appear histologically papillary dermis accompanied by regression. Kortikoksteroid cause thinning of the epidermis and dermis due antiproliferatif activity on keratinocytes and fibroblasts. This depletion resulted in visualization of blood vessels that appeared telangiektasi, or superficial because of collagen loss of the buffer wall. While striae, although not yet clear how it happened, but the main factor is the effect on collagen fibers and elastin.5
Steroid acne Characterized by monomorphic form of papulopustular follicular eruption mainly on the upper body, upper arms and wajah.1, 3.4 The disorder is more frequently encountered in the use of stocks with strong potential, but sometimes due to the weaker potency dosage plus dressing oklusi.1 This is due to degeneration of follicular epithelium, causing evisceration folikel.1 In the existing acne lesions, first corticosteroid would suppress the inflammatory reaction, but soon grew with new lesions and with stopping the drug would appear pustulasi.1, 4 Purpura, stellate Pseudoscar, ulceration As a result of the severe dermal atrophy and loss of ground substance, blood vessels without losing the buffer that can be avoided be easily broken if only because of minor trauma. Slightest trauma can cause bleeding and even skin erosion and ulceration, and therefore there is little protection against the blood vessel due to thinning of the dermis. Purpuric lesions are absorbed slowly and sunken scar, hypopigmentation irregular shape (stellate Pseudoscar). Stellate Pseudoscar is most often found in the extremities, especially the extensor surfaces of arms bawah.4 On the skin is thinned, for example in the elderly, these lesions are also more easily arise. In the end the actual ulceration can occur. Perioral Dermatitis The disorder is characterized by follicular papules and pustules on erythematous skin in the perioral area (around the mouth) and it was evident lesion-free areas in Vermillion border.1, 4.5 Often seen in women using topical kortilosteroid strong potential in wajah.1, 4.5 fluorinated topical corticosteroid is considered as the main cause. Rosacea The use of topical corticosteroids strong or very strong potential in the face will exacerbate existing rosacea and can trigger a picture like rosacea with erythema, papules, pustules, telangiektasi on the cheeks, nose and dahi.1, 4 Rosacea is a condition characterized by symptoms of facial burning and pustulasi. The use of topical corticosteroids, often provide repairs to the complaint, but as time passes, diperlukansediaan yanglebih application of more powerful and frequent. When the drug was discontinued, there will be a severe rebound phenomenon characterized by erythema, pustulasi, telagniektasi as noted diatas.3, 5 The mechanism of the emergence of dependence on corticosteroids are believed to go through three phases namely: 1. The use of corticosteroids relieve erythema, puspula, skuama and pruritus due to anti-inflammatory effects. 2. The continued provision of corticosteroids lead to increased microbial growth because of the effect of local immunosuppression. 3. By stopping the drug, no longer depressed immune response so that the redness, pustulasi, skuama and failed to re-emerge due to the increasingly severe infection. Cover (veil) and aggravate skin infections Topical corticosteroids are often given in tidka right to abnormalities of primary infection of the skin. Eruption would have improved due to suppression of inflammatory processes so that a closed or clinical signs of infection-causing organisms do not change while diberantas.4 One theory is that corticosteroids inhibit the transcription of genes coding for peptide antibakterial.1 For example, the use of topical corticosteroids on tinea cause atypical clinical picture in which a rising edge, erythematous and bounded strictly not available anymore, so the limit becomes blurred and expanding known as Tinea Inkognito.4 This line caused by the suppression of inflammation, but the fungus continued to flourish. Corticosteroids also aggravate viral infections, particularly in patients with atopic dermatitis. Granuloma Gluteale Infantum Papulonodular eruption characterized by the presence or blackish red nodulus on the buttocks, thighs or baby genetalia area that has been treated as an existing diaper rash sebelumnya.2, 4 Although the exact etiology is unknown, but suspected pemakaina strong potency topical corticosteroid that is applied under closure plastic pants, which alter the response to candida infection as penyebabnya.4 With the cessation kkostikosteriod, lesions will slowly disappear, but leave the scar atrofik.4
Hepertrikosis Especially prevalent in women who use topical kortikostetoid kkuat potential in wajah.1 Although the drug has been discontinued, velus hairs darker and larger is to survive for several months. The mechanism of hair growth velus more harshly by the impulse is not known kortikosteriod pasti.1 Hypopigmentation Although known as a side effect that many occurred after intralesional injection kostikosteroid, but hypopigmentation is often encountered after administration of topical corticosteroids. Especially in patients with skin hitam.1 In this regard, corticosteroids interfere with melanin synthesis by melanosit.1 Impaired Wound Healing On the use of topical corticosteroids may occur obstacles healing wounds that had existed before, because the anti-inflammatory properties of this preparation through: 1. Stock vasoconstriction of small blood vessels so that extravasation of leukocytes and plasma exudation disturbed. 2. Decrease the number of leukocytes in inflammation. 3. Decrease in reactivity of connective tissue disorder because of the formation of fibroblasts, ground substance and tissue granulation. So, in summary, these adverse effects, due to declining enrollment kegagaln inflammatory response and collagen and fibrin. Allergic contact dermatitis Topical corticosteroid preparations may cause contact dermatitis of both corticosteroid molecule itself, although very rare, and often against vehikulum or various kompinen contained therein, such as preservatives, emulsifier, stabilizer. Not infrequently cross reaction between the dosage of corticosteroids which have molecular structures that serupa.1 Optalmik disorders (ocular) The use of topical corticosteroids, especially the strong potential of the eyelids or periorbital, should be closely monitored, because of the risk for the occurrence of glaucoma, cataracts, and hypertension okular.1, 4 One study showed that ocular hypertension as a result of the use of dexamethasone typical, more frequent, more intense and faster arise in young anak.1 Adverse effects on the eye has arisen as a result of the ability of corticosteroids to increase the intraocular pressure. Should only a mild potency corticosteroid used in the vicinity mata.5 Takifilasis A phenomenon in which the use of topical corticosteroids continuously cause of acute tolerance with reduced efficacy or efficacy tersebut.1 preparations, 4.5 SYSTEMIC SIDE EFFECTS Systemic side effects may occur, if kortikkosteroid systemically absorbed topical or absorbed in sufficient amount into the systemic impact sirkulasi.4 this can happen to all uses of topical corticosteroids. The risk of such absorption will increase in the skin that is thinner, stronger dosage, younger age, use of the older and the presence of occlusion (pemabalutan). In other words, the risk factors for the occurrence of systemic effects include: use in infants and children, the use of a long and excessive, the use of strong-potency preparations are very strong, the use of large areas and the use of bandage oklusi.1, 2 One of the alarming effects of the dross of hypothalamic pituitary axis suppression adalha Adrenal (HPA) or the HPA axis. All use of topical corticosteroids can lead to inappropriate emphasis, but generally occurs in the use of the stocks are very kuat.1 potential, 3 HPA axis suppression resulted in no disekresinya adrenokortikosteroid endogenous, resulting in adrenal insufficiency, in which the parameters appear is the reduction of cortisol levels plasma.3, 5 In addition to HPA axis suppression, may also result from hypertension, hyperglycemia, osteroporosis, particularly growth disorders in children, Cushing's syndrome and sebagainya.3, 4 USE IN CHILDREN Topical corticosteroids are highly effective preparation for the children and found only mild side effects when used in low potency corticosteroid, in a short span of time, without dressing oklusi.3 However, in infants there is an increased risk for side effects because of greater body surface area ratio of weight and kekurangmampuan for drug metabolism in cepat.2, 3.5 Especially in premature infants, due to thinner skin, the degree of penetration of topical medications to be very meningkat.2, 3 Similarly, the application of corticosteroids in the diaper area, causing occlusion of the drug by the diaper so that there was an increase penetrasi.3 Excessive absorption may cause penenkanan prosuksi endogenous cortisol, and therefore after the cessation of topical corticosteroid pemakaina period of time, can cause a condition called Addison's crisis with symptoms of nausea, anorexia, hypotension postular from collapse vaskular.1, 3 Chronic suppression of cortisol production may also cause retardation pertumbuhan.1, 3 CLOSING Side effects of topical corticosteroid use occurred at several levels, namely: Epidermal Effects Depletion of epidermal punurunan associated with epidermal kinetic activity, decreasing the thickness of the layer of keratinocytes, and leveling link dermoepidermal. Inhibition melanocytes. Dermal Effects Decrease collagen synthesis and reduction of ground substance that causes strike and the fragility of the network buffer dermal blood vessels so that spread easily cause bleeding spots which form the stellate scar healing. Vascular Effects settle vasodilatation At first, corticosteroids cause vasoconstriction of small blood vessels are superficial vasodilatation followed by a rebound phase, where at the final stage to settle. The phenomenon of rebound When vasoconstriction disappeared, the small blood vessels experiencing excessive dilatation causing edema, increased inflammation and sometimes pustulasi. Systemic absorption Emphasis HPA axis Cushing's syndrome growth retardation Given the vast and dangerous effects of topical corticosteroid use is less precise, so to avoid it, in providing treatment should be guided kapada 4T, 1W namely: Appropriate Indications Right Medication Right Patient Right Dose Beware Side Effects Literature 1. Anigbogu AN, Maibach HI. Coeticosteroid Topical Therapy. In: LE appropriation editor.Drug Therapy In Dermatology. New York: Marcel Dekker Inc; 2000. p. 1-23. 2. Lee M, Marks R. The Role of Corticosteroids in Dermatology. Aust Prescr 1998; 21: 90-10. 3. Baumann L, Kerdel F. Topical glucocorticoids. In: Freedberg IM, Eisen AZ, Wolff K, Goldsmith LA, Katz General Medicine. 5th ed. New York: McGraw Hill; 1999.p.2713-17 4. Clement M, Du Vivier A. Topical Steroids for Skin Disorders. 1st ed. USA: Blacwell Scintific Pulications; 1987.p.1-62. 5. Cornell RC, Stoughton RB. Topical Corticosteroids. Guidelines for Therapy. Up-Date Medication Hoechst 1985.p.6-63.
Edting By: EnongXp
Steroid acne Characterized by monomorphic form of papulopustular follicular eruption mainly on the upper body, upper arms and wajah.1, 3.4 The disorder is more frequently encountered in the use of stocks with strong potential, but sometimes due to the weaker potency dosage plus dressing oklusi.1 This is due to degeneration of follicular epithelium, causing evisceration folikel.1 In the existing acne lesions, first corticosteroid would suppress the inflammatory reaction, but soon grew with new lesions and with stopping the drug would appear pustulasi.1, 4 Purpura, stellate Pseudoscar, ulceration As a result of the severe dermal atrophy and loss of ground substance, blood vessels without losing the buffer that can be avoided be easily broken if only because of minor trauma. Slightest trauma can cause bleeding and even skin erosion and ulceration, and therefore there is little protection against the blood vessel due to thinning of the dermis. Purpuric lesions are absorbed slowly and sunken scar, hypopigmentation irregular shape (stellate Pseudoscar). Stellate Pseudoscar is most often found in the extremities, especially the extensor surfaces of arms bawah.4 On the skin is thinned, for example in the elderly, these lesions are also more easily arise. In the end the actual ulceration can occur. Perioral Dermatitis The disorder is characterized by follicular papules and pustules on erythematous skin in the perioral area (around the mouth) and it was evident lesion-free areas in Vermillion border.1, 4.5 Often seen in women using topical kortilosteroid strong potential in wajah.1, 4.5 fluorinated topical corticosteroid is considered as the main cause. Rosacea The use of topical corticosteroids strong or very strong potential in the face will exacerbate existing rosacea and can trigger a picture like rosacea with erythema, papules, pustules, telangiektasi on the cheeks, nose and dahi.1, 4 Rosacea is a condition characterized by symptoms of facial burning and pustulasi. The use of topical corticosteroids, often provide repairs to the complaint, but as time passes, diperlukansediaan yanglebih application of more powerful and frequent. When the drug was discontinued, there will be a severe rebound phenomenon characterized by erythema, pustulasi, telagniektasi as noted diatas.3, 5 The mechanism of the emergence of dependence on corticosteroids are believed to go through three phases namely: 1. The use of corticosteroids relieve erythema, puspula, skuama and pruritus due to anti-inflammatory effects. 2. The continued provision of corticosteroids lead to increased microbial growth because of the effect of local immunosuppression. 3. By stopping the drug, no longer depressed immune response so that the redness, pustulasi, skuama and failed to re-emerge due to the increasingly severe infection. Cover (veil) and aggravate skin infections Topical corticosteroids are often given in tidka right to abnormalities of primary infection of the skin. Eruption would have improved due to suppression of inflammatory processes so that a closed or clinical signs of infection-causing organisms do not change while diberantas.4 One theory is that corticosteroids inhibit the transcription of genes coding for peptide antibakterial.1 For example, the use of topical corticosteroids on tinea cause atypical clinical picture in which a rising edge, erythematous and bounded strictly not available anymore, so the limit becomes blurred and expanding known as Tinea Inkognito.4 This line caused by the suppression of inflammation, but the fungus continued to flourish. Corticosteroids also aggravate viral infections, particularly in patients with atopic dermatitis. Granuloma Gluteale Infantum Papulonodular eruption characterized by the presence or blackish red nodulus on the buttocks, thighs or baby genetalia area that has been treated as an existing diaper rash sebelumnya.2, 4 Although the exact etiology is unknown, but suspected pemakaina strong potency topical corticosteroid that is applied under closure plastic pants, which alter the response to candida infection as penyebabnya.4 With the cessation kkostikosteriod, lesions will slowly disappear, but leave the scar atrofik.4
Hepertrikosis Especially prevalent in women who use topical kortikostetoid kkuat potential in wajah.1 Although the drug has been discontinued, velus hairs darker and larger is to survive for several months. The mechanism of hair growth velus more harshly by the impulse is not known kortikosteriod pasti.1 Hypopigmentation Although known as a side effect that many occurred after intralesional injection kostikosteroid, but hypopigmentation is often encountered after administration of topical corticosteroids. Especially in patients with skin hitam.1 In this regard, corticosteroids interfere with melanin synthesis by melanosit.1 Impaired Wound Healing On the use of topical corticosteroids may occur obstacles healing wounds that had existed before, because the anti-inflammatory properties of this preparation through: 1. Stock vasoconstriction of small blood vessels so that extravasation of leukocytes and plasma exudation disturbed. 2. Decrease the number of leukocytes in inflammation. 3. Decrease in reactivity of connective tissue disorder because of the formation of fibroblasts, ground substance and tissue granulation. So, in summary, these adverse effects, due to declining enrollment kegagaln inflammatory response and collagen and fibrin. Allergic contact dermatitis Topical corticosteroid preparations may cause contact dermatitis of both corticosteroid molecule itself, although very rare, and often against vehikulum or various kompinen contained therein, such as preservatives, emulsifier, stabilizer. Not infrequently cross reaction between the dosage of corticosteroids which have molecular structures that serupa.1 Optalmik disorders (ocular) The use of topical corticosteroids, especially the strong potential of the eyelids or periorbital, should be closely monitored, because of the risk for the occurrence of glaucoma, cataracts, and hypertension okular.1, 4 One study showed that ocular hypertension as a result of the use of dexamethasone typical, more frequent, more intense and faster arise in young anak.1 Adverse effects on the eye has arisen as a result of the ability of corticosteroids to increase the intraocular pressure. Should only a mild potency corticosteroid used in the vicinity mata.5 Takifilasis A phenomenon in which the use of topical corticosteroids continuously cause of acute tolerance with reduced efficacy or efficacy tersebut.1 preparations, 4.5 SYSTEMIC SIDE EFFECTS Systemic side effects may occur, if kortikkosteroid systemically absorbed topical or absorbed in sufficient amount into the systemic impact sirkulasi.4 this can happen to all uses of topical corticosteroids. The risk of such absorption will increase in the skin that is thinner, stronger dosage, younger age, use of the older and the presence of occlusion (pemabalutan). In other words, the risk factors for the occurrence of systemic effects include: use in infants and children, the use of a long and excessive, the use of strong-potency preparations are very strong, the use of large areas and the use of bandage oklusi.1, 2 One of the alarming effects of the dross of hypothalamic pituitary axis suppression adalha Adrenal (HPA) or the HPA axis. All use of topical corticosteroids can lead to inappropriate emphasis, but generally occurs in the use of the stocks are very kuat.1 potential, 3 HPA axis suppression resulted in no disekresinya adrenokortikosteroid endogenous, resulting in adrenal insufficiency, in which the parameters appear is the reduction of cortisol levels plasma.3, 5 In addition to HPA axis suppression, may also result from hypertension, hyperglycemia, osteroporosis, particularly growth disorders in children, Cushing's syndrome and sebagainya.3, 4 USE IN CHILDREN Topical corticosteroids are highly effective preparation for the children and found only mild side effects when used in low potency corticosteroid, in a short span of time, without dressing oklusi.3 However, in infants there is an increased risk for side effects because of greater body surface area ratio of weight and kekurangmampuan for drug metabolism in cepat.2, 3.5 Especially in premature infants, due to thinner skin, the degree of penetration of topical medications to be very meningkat.2, 3 Similarly, the application of corticosteroids in the diaper area, causing occlusion of the drug by the diaper so that there was an increase penetrasi.3 Excessive absorption may cause penenkanan prosuksi endogenous cortisol, and therefore after the cessation of topical corticosteroid pemakaina period of time, can cause a condition called Addison's crisis with symptoms of nausea, anorexia, hypotension postular from collapse vaskular.1, 3 Chronic suppression of cortisol production may also cause retardation pertumbuhan.1, 3 CLOSING Side effects of topical corticosteroid use occurred at several levels, namely: Epidermal Effects Depletion of epidermal punurunan associated with epidermal kinetic activity, decreasing the thickness of the layer of keratinocytes, and leveling link dermoepidermal. Inhibition melanocytes. Dermal Effects Decrease collagen synthesis and reduction of ground substance that causes strike and the fragility of the network buffer dermal blood vessels so that spread easily cause bleeding spots which form the stellate scar healing. Vascular Effects settle vasodilatation At first, corticosteroids cause vasoconstriction of small blood vessels are superficial vasodilatation followed by a rebound phase, where at the final stage to settle. The phenomenon of rebound When vasoconstriction disappeared, the small blood vessels experiencing excessive dilatation causing edema, increased inflammation and sometimes pustulasi. Systemic absorption Emphasis HPA axis Cushing's syndrome growth retardation Given the vast and dangerous effects of topical corticosteroid use is less precise, so to avoid it, in providing treatment should be guided kapada 4T, 1W namely: Appropriate Indications Right Medication Right Patient Right Dose Beware Side Effects Literature 1. Anigbogu AN, Maibach HI. Coeticosteroid Topical Therapy. In: LE appropriation editor.Drug Therapy In Dermatology. New York: Marcel Dekker Inc; 2000. p. 1-23. 2. Lee M, Marks R. The Role of Corticosteroids in Dermatology. Aust Prescr 1998; 21: 90-10. 3. Baumann L, Kerdel F. Topical glucocorticoids. In: Freedberg IM, Eisen AZ, Wolff K, Goldsmith LA, Katz General Medicine. 5th ed. New York: McGraw Hill; 1999.p.2713-17 4. Clement M, Du Vivier A. Topical Steroids for Skin Disorders. 1st ed. USA: Blacwell Scintific Pulications; 1987.p.1-62. 5. Cornell RC, Stoughton RB. Topical Corticosteroids. Guidelines for Therapy. Up-Date Medication Hoechst 1985.p.6-63.
Edting By: EnongXp
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