Topical Steroid Label

Whenever we purchase a prescription, there is always an insert or attached label outlining that specific drug’s usage. More often than not, we toss it into the trash. What we should be doing is taking the time to read the insert because it holds extremely valuable information. However, on the contrary, there is misguided information that needs to be looked at closely.

The following is seen on the insert for Clobetasol Propionate, a Class 1 Super Potent steroid:

In bold letters: do not use for more than 2 weeks, 50g per week, because it can suppress the HPA axis.

First off, it warns not use to this for more than 14 days. What it does not say is “Do not use for more than 14 days unless your doctor thinks it’s cool.” There is a definite reason why it states that warning despite what your doctor tells you.

HPA axis suppression is not something you, or your doctor, should take lightly. You are highly increasing your chances of developing Red Skin Syndrome and creating an imbalance in your adrenal glands.

Also, what does 50g a week mean to you? Most likely nothing because you are not a doctor and have no idea how to measure out 50g.

Let’s say your doctor gave you a tube that was 60g large, and their instructions were to “use on flaring areas once a day.” That was it. That was all they told you. Well, your thighs, hands, elbow area, and neck are flaring. These areas combined, using the fingertip method, come out to around 10g a day of use. 10g x 7 days = 70g a week. That is over the maximum limit of use.

But let’s take this further. In bold, the insert states:

“Precautions: General: Clobetasol Propionate is a highly potent topical corticosteroid that has been shown to suppress the HPA axis at doses as low as 2g per day.”

2g per day! That is around 4 fingertip units a day.

2g x 7 days a week = 14g a week. So, more accurately, 50g a week is WAY too much. Even if 14g a week is seen as the ‘minimum’ to cause HPA axis suppression, that means THERE IS A POSSIBILITY it can happen with just 14g a week, which in turn shows there is a LARGE POSSIBILITY it will happen at the ‘safe usage’ of 50g a week.

That 36g difference is remarkable. This is something that rarely ever gets explained in a doctor’s office. When a doctor gives you the instruction to “use sparingly”, this is what they should be explaining to you.

But let’s move on.

When using steroids, adults are not equal to children.

“Pediatric patients may be more susceptible to systemic toxicity from equivalent doses due to their large skin surface to body mass ratios.”

First off, the word systemic should bounce out. If any doctor tells you that topical steroids “are not systemic”, they are lying to you. Just because you are not orally using them, does not mean they do not penetrate our skin and enter our system.

And two, this should put up a huge warning flag. If 14g a week is the lowest dose they saw suppression in for adults, try halving that, or even one quarter. That would be between 4g and 8g a week for small children and babies. And, because they are smaller, there is a larger chance of suppression. Besides, in bold caps, the insert says, “Use in children under 12 years of age is not recommended.” If a doctor prescribes this to a child under 12, especially a baby, know that this recommendation should read more as a forbiddance.

“If concomitant skin infections are present or develop, an appropriate antifungal or antibacterial agent should be used. If a favorable response does not occur promptly, use of clobetasol propionate should be discontinued until the infection has been adequately controlled.”

First off, you’ve got the vague “promptly” in there. Give us actual numbers, perhaps, “1-2 days”. And secondly, you should NEVER use steroids on an infection. It will just make them worse. Check out Tinea Incognito.

“#5 Patients should inform their physicians that they are using clobetasol propionate if surgery in contemplated.”

I had never heard of this before, so I do hope this information is shared in the doctor’s office and not left for the patient to (not) read in the insert.

And last, but certainly not least, in lovely bold writing, “should not be used on the face, groin, or axiliae”. This isn’t a recommendation. This is a definite warning.

Feature #3: Megan & Sheryl

Megan Garza megan-garza

Age: 25

Career: Unemployed due to TSW

When did you cease using topical steroids: September 2014 last application of TS

What type did you use: Clobetasol, Triamcinolone, Fluocinolone and Protopic 0.1% ( I’ve also been on iv/ oral rounds)

What is your favorite product for comfort? Lemongrass balm, avene thermal spring water, & organic rose water

What is the hardest thing to deal with during this condition? The beginning days of TSW when I had cracks all over my face/ neck and oozing. Having my hands completely covered with RSS as well as oozing blisters on all my fingers. Self esteem has been shot down completely due to TSW as well as having anxiety.

What is the first thing you will do when healed? Wear a short sleeve shirt with jean shorts. Then I would take off to a beach and wear a bikini 24/7 and soaking up some sun rays.


sherylmorrisSheryl Morris

Age: 36

Career: Systems Support Officer, University of Dundee, Scotland

When did you cease using topical steroids: 1st time Sep 2010, 2nd time was 6th Jan 2013 (however was on orals between Mar 2013 and Dec 2013). Date stopped using any type of steroids 21st Dec 2013

What type did you use: Hydrocortisone, Elocon, Dermovate, Betnovate creams/ointments. Also used Haelan Tape (tape impregnated with steroids), oral steroids (prednisolone), hair mousse (betnovate in it)

What is your favorite product for comfort? The turning point for me came when I started using a combination of Milton bleach solution on patches skin that kept getting infected along with Manuka honey under cotton gloves for my hands overnight. I also found using Moogoo shampoo, conditioner, baby bubbles wash and nut oil free moisturiser really helping. I also use a nettle moisturisers made locally in Scotland. I used several different products over the years, some helped at different stages of the process – for example, heavy 50/50 really helped my skin when it was red raw but trapped heat and bacteria in so in the long run actually made it worse, and more itchy.

What is the hardest thing to deal with during this condition? Recurring skin infections, lack of support from doctors/dermatologists, the uncontrollable itch, the pain, the wet feeling of ooze, feeling disgusted, the flakes of skin EVERYWHERE, depression, anxiety

What is the first thing you did when you healed? First thing I did when I got my first real break was go to Glastonbury festival and few months later got married, I did have several skin infections after this so it took a while longer before I felt truly healed.


 

Interview #1: Joey VanDyke

JoAnne (Joey) VanDyke14364711_10208836120492432_2954530378884912840_n
Southwest Michigan

“Three things will last forever–faith, hope, and love–and the greatest of these is love” – Apostle Paul

When did you start using topical steroids? I don’t know exactly what age as I had eczema as a baby, but I’ve used it since childhood. My older sisters remember my mother rubbing some kind of cream on the inside of my knees and elbows and putting socks on my hands every night when I was young. I remember chewing holes in the socks to scratch.

What was the name of the topical steroid? I only remember a few names of TS since my eczema started in my infant days and my mother may have used them on me as well. Aristocort, Westcort, Kenalog and Triamcinalone.

Were you ever prescribed more potent steroids? I think the ones I was prescribed were pretty much the same strength as my fingers would clear well with the ones I used.



How did you find out about RSS? It took about five months of trying to fix my skin myself with various remedies before I found out about Red Skin Syndrome. The TS stopped working for me at age 55 in late September 2010 and my chest and stomach broke out into progressive weird, itchy hives all that would not clear up, even with the steroids. My doctor prescribed oral steroids for me but I did not take them at that point.I surfed the internet and found Dr. Wheatgrass’ forum and emailed him for help. He advised me through his online support group to use small amount of oral steroids and to keep tapering down from them until it cleared, but after a few weeks of that, I realized it only delayed the inevitable.

By this time, of five months into ceasing all topical steroids and trying orals, I was desperate. My body now had all kinds of symptoms going on, spreading rashes, red, hot burning skin over much of it and the classic “red sleeve” on both arms that distigushes Red Skin Syndrome from eczema and other skin diseases.

I ended up surfing the internet once again in total anxiety with the phrase “steroid cream side-effects” and Kelly Palace’s “Addicted Skin” website popped up. I immedieately emailed her and she answered me back the next day, explaining her red skin symptoms and I had that emotional light bulb moment so many of us describe. I joined her small Google support group and learned all about Red Skin Syndrome there and got heavily proactive in the cause to prevent RSS and find ways to treat or cure it.

What made you feel you had RSS? The many symptoms of itchy hives, spreading rashes, hot, burning skin, lumps, freezing cold, sweating, insomnia, nerve zingers, weight loss, eye problems, “elephant” skin, insane itching and flaking… did not match any eczema I’d ever experienced. Once I saw Kelly’s same symptom pics, heard her story along with the others in the support group, I knew I had the same steroid-induced disease as they did.

Were you diagnosed by a doctor? No, my doctor had never heard of steroid-induced anything and was at a loss for what it was. Dr. Rapaport eventually spoke with her on the phone and explained RSS to her and how to keep me comfortable the best she could.

Did you have a supportive doctor? Yes! She went above and beyond to see me when I needed her,  monitor my symptoms, listen to concerns, prescribe comfort meds and check my bloodwork. She felt very bad that this physical trauma had happened to me. She is now supportive of my work with ITSAN and any patient that would come to her with it.

What were your first symptoms? Oddly enough, mine were itchy hives and then spreading rashes. The burning hot skin and red sleeves did not manifest until five months after stopping TS. Some people are what I call “slow burners” like I was.

Was/Is your family supportive? Friends? Yes, my family was very supportive as they had never seen me this sick. It felt like I was going through Chemo treatments, had third degree burns and was literally wasting away. They were scared and stood by me lovingly and immensely. My grandchildren made me get well cards and poems often, which would bring on a river of tears every time  they brought them to me. Friends were not as supportive, simply because they didn’t know what to say or do and I could not visit with anyone very long due to the scratching and living mostly in my bathtub and bedroom for two years.

Have you ever been to a hospital for this? Why? Yes, I was peaking in my worst symptoms in November and December 2011, which was 15 months after stopping TS. I had sever nerve pain all over my body which could have been intensified by the fibromyalgia that I had been diagnosed with in 2000. I had such bad nerve pain and was so red and frail that I could not function anymore and thought I had sepsis.   I went to the ER and the doctor said I did not have sepsis and wanted to prescribe oral steroid for me. I refused and he walked out of the room and said he could not help me then.

Two weeks later I went into another local hospital ER with extreme nerve pain, burning and fatigue, still. This doctor was a lady who believed me and she gave me an IV of pain meds, sedative and stomach buffers. I ended up using those meds and others often for the next 15 months as my journey was hard.

What was the hardest part of this disease? The 24-7 nerve pain and bone deep itching that lasted way too long.

How long did RSS last for you? A total of 62 months but the worst phase was for 27 months. About 98 per cent of my skin healed after 27 months but it took another 35 months of very slow, almost stagnant healing on that last 2% of my skin to heal.

What did you use as comfort measures during this time? Prayer, keeping hope and releasing my tears often. Hot Epsom salt baths about six times a day, heating pad or hot water bottle, white palm oil, vinyl gloves on my hands and various meds.

Are you employed? Fortunately, I was not employed as the fibromyalgia I was diagnosed with and a ruptured disc in my back had taken me out of the physical work force years prior.  I spent all my time when not in the bathtub, helping others in the support group.

Have you gone to therapy or wish you had? I have been to therapy before due to past trauma in my life resulting in PTSD so I utilized all of my counseling “tools” and did the best to keep myself sane and hopeful. The support groups were a lot of therapy for me and that is why I started a couple more.  I now go to physical therapy once a month for osteoarthritis, fibromyalgia and chronic joint and bone problems, which I strongly suspect were helped along by the steroids. My hope is that my body is still healing on the inside as well as my skin did.

If there is one thing you could say to another sufferer, what would it be? You are not alone. Take this one hour at a time and don’t set a time for your recovery, it’s too discouraging when it does not end when you think it should. Keep hope in your mind and heart for healing, even if it’s not the total healing you desire. This is not a lifetime disease, many RSS vets have come through this recovered and gone on with their lives.  It’s not what happens to us in life but how we respond. This suffering can make you a better, more compassionate person if you allow it.  Become proactive to help get RSS known and prevented. Share your story, encourage others and stay positive. This will pass!


Thank you Joey for such a great interview!

Feature #2: Ava & Christine

Ava Knappava-knapp

Age: 5 years old

Career: I start kindergarten next year

When did you cease using topical steroids: January 16, 2016

What type did you use: All kinds but chlobetasol foam .05%  is the last one I used.

What is your favorite product for comfort? Homemade zinc cream and Dead Sea salt baths

What is the hardest thing to deal with during this condition? The burning and itching has been the hardest part. I really didn’t like all the skin I found in my bed. I’ve lost a lot of hair and some fingernails along the way, too.

What is the first thing you will do when healed? Wear dresses and sandals comfortably!! I also want to take a dance class again and be able to wear the recital outfit without having a reaction this time.


christine-lozanoChristine Lozano

Age: 26

Career: Marriage & Family Therapist

When did you cease using topical steroids: June 15, 2016

What type did you use: Not sure exact names of topicals, but many different creams/ointments of various strengths. Most recently used oral steroids (Prednisone) April-June 2016 (for 8 weeks)

What is your favorite product for comfort? Zinc cream. Many natural supplements prescribed from my wonderful naturopthic doctor.

What is the hardest thing to deal with during this condition? There are absolutely no words that could describe the physical, mental, and emotional pain of this journey. Every single day-to-day activity became an excruciatingly painful moment.

What is the first thing you will do when healed? I wouldn’t consider myself healed, but I’m in the process! When I am healed, I will exercise, sweat, take a completely pain-free shower, and smile.


 

Medical Terminology Explained

One of the many ways we can feel left out of the medical loop is the jargon that leaves us perplexed and, most likely, uninterested in trying to understand our ailment. The doctor either says some fancy words or we end up reading a pamphlet that looks like ancient hieroglyphics. It can be daunting and when we just want relief, we don’t delve any further than the reaching to take a prescription from the doctor.

The time has come for us to decipher some very important medical terminology so we, as patients, can be best informed about our condition and what may lie ahead if we take a certain treatment.


Antiproliferative: of or relating to a substance used to prevent or retard the spread of cells, especially malignant cells, into surrounding tissues.

Atherosclerosis: a disease in which plaque builds up inside your arteries. This can cause different problems including coronary heart disease, carotid artery disease, and chronic kidney disease.

Atrophy: waste away, typically due to the degeneration of cells, or become vestigial during evolution. Picture

Axillae: Armpit

Bioethics: the study of the typically controversial ethical issues emerging from new situations and possibilities brought about by advances in biology and medicine. It is also moral discernment as it relates to medical policy and practice.

Corticosteroids: any of a group of steroid hormones produced in the adrenal cortex or made synthetically. There are two kinds: glucocorticoids and mineralocorticoids. They have various metabolic functions and some are used to treat inflammation. The ones we usually deal with are glucocorticoids that stop inflammation.

Candidiasis: infection by fungi of the genus Candida, generally C. albicans, most commonlyinvolving the skin, oral mucosa (thrush), respiratory tract, or vagina; occasionally thereis a systemic infection or endocarditis. It is most often associated with pregnancy,glycosuria, diabetes mellitus, or use of antibiotics. Picture

Concomitant: naturally accompanying or associated.

Cutaneous: of, relating to, or affecting the skin.

Demodicidosis: skin disease of the pilosebaceous units associated with human Demodex mites that involves predominantly the face and head. Picture

Edema: a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body. Picture

Efficacy: the ability to produce a desired or intended result.

Emollient: a preparation that softens the skin.

Erythema: superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries. Picture

Exacerbation: an increase in the severity of a disease or its signs and symptoms; a worsening.

Granuloma Gluteale Infantum: a rare skin disorder of controversial etiology characterized by oval, reddish purple granulomatous nodules on the gluteal surfaces. Picture

Gynecomastia: enlargement of a man’s breasts, usually due to hormone imbalance or hormone therapy. Picture

Hirsutism: abnormal growth of hair on a person’s face and body, especially on a woman. Picture

HPA axis: The hypothalamic–pituitary–adrenal axis is a complex set of direct influences and feedback interactions among three endocrine glands: the hypothalamus, the pituitary gland(a pea-shaped structure located below the hypothalamus), and the adrenal (also called “suprarenal”) glands (small, conical organs on top of the kidneys).

Hyperkeratosis: thickening of the stratum corneum (the outermost layer of the epidermis, or skin), often associated with the presence of an abnormal quantity of keratin, and also usually accompanied by an increase in the granular layer. Picture

Hyperpigmentation: the darkening of an area of skin or nails caused by increased melanin.

Hypertrichosifs: a skin abnormality that results in excessive growth of hair. It can be localized to one part of the body, or affect in full. It can affect men or women and is mostly secondary to a genetic disease that causes a hormonal disorder. Picture

Hypopigmentation: the loss of skin color. It is caused by melanocyte or melanin depletion, or a decrease in the amino acid tyrosine, which is used by melanocytes to make melanin. Picture

Iatrogenic: of or relating to illness caused by medical examination or treatment.

Immunosuppressive: (chiefly of drugs) partially or completely suppressing the immune response of an individual. Topically, there is Protopic and Elidel.

Impetigo: a contagious bacterial skin infection forming pustules and yellow, crusty sores. Picture

In vivo: (of a process) performed or taking place in a living organism.

Intertriginous: area where two skin areas may touch or rub together, like armpit or groin

Kaposi Sarcoma: a rare tumor that is named after the dermatologist who first described it in 1872. It is caused by a type of herpesvirus. Picture

Lichen Sclerosis: an uncommon condition that creates patchy, white skin that’s thinner than normal. Picture

Malassezia Folliculitis: an inflammatory skin disorder that typically manifests as a pruritic, follicular papulopustular eruption distributed on the upper trunk of young to middle-aged adults. Picture

Mastocytosis: disorder that can occur in both children and adults. It is caused by the presence of too many mast cells in your body. You can find mast cells in skin, lymph nodes, internal organs (such as the liver and spleen) and the linings of the lung, stomach, and intestine. Picture

Milia: a small white or yellowish nodule resembling a millet seed, produced in the skin by the retention of sebaceous secretion. Picture

Molluscum Contagiosum: a chronic viral disorder of the skin characterized by groups of small, smooth, painless pinkish nodules with a central depression, that yield a milky fluid when squeezed. Picture

Morbidity: is a term used to describe how often a disease occurs in a specific area.

Occlusive: Of or being a bandage or dressing that closes a wound and keeps it from the air.

Ocular Hypertension: an eye pressure of greater than 21 mm Hg. It usually occurs for a long time and doesn’t match with glaucoma.

Perioral Dermatitis: a common skin rash that mainly affects young women. The rash affects the skin around the mouth. Use of a steroid cream on the face seems to trigger the condition in many cases. Picture

Phimosis: a congenital narrowing of the opening of the foreskin so that it cannot be retracted.

Purpura: a rash of purple spots on the skin caused by internal bleeding from small blood vessels. Picture

Stellate Pseudoscars: white, irregular or star-shaped atrophic scars occurring over the sun-exposed areas of the forearms. Picture

Stratum Corneum: the horny outer layer of the skin.

Striae: a linear mark, slight ridge, or groove on a surface, often one of a number of similar parallel features. Picture

Synthetic: made by chemical synthesis, especially to imitate a natural product.

Systemic: of, relating to, or affecting the entire body.

Tachyphylaxis: rapidly diminishing response to successive doses of a drug, rendering it less effective. The effect is common with drugs acting on the nervous system.

Telangiectasia: a condition characterized by dilation of the capillaries, which causes them to appear as small red or purple clusters, often spidery in appearance, on the skin or the surface of an organ. Picture

Tinea Incognito: a fungal infection (mycosis) of the skin masked and often exacerbated by application of a topical immunosuppressive agent. The usual agent is a topical corticosteroid (topical steroid). Picture

Vasoconstriction: the constriction of blood vessels, which increases blood pressure.

Vitiligo: a condition in which the pigment is lost from areas of the skin, causing whitish patches, often with no clear cause. Picture