Topical Steroid Label Part II

Class 1 steroids, like Clobetasol Propionate, will always be the ones you see in studies showing bigger problems than less potent classes. However, that does not mean less point steroids are super safe.

So, I looked up the insert for the steroid I used, Alclometasone Dipropionate, which is a Class 6 steroid (Classes range from 1-7, 1 being the highest).

“May be used in patients 1 year of age and older, although safety efficacy of drug use for longer than 3 weeks have not been established.”

Not…. been… established. That translates into “we don’t know anymore after 3 weeks.” Also, it should NOT be used in children under 1 year old (although my personal belief is to steer clear of steroids on newborn skin).

The insert says to apply 2-3 times daily. We still see wavering views on this subject, some research showing putting on steroids creams more than once a day does not increase the likelihood of it working, but actually just increases your chances of overusing. Source

“If no improvement is seen within 2 weeks, reassessment of diagnosis may be necessary.” This doesn’t say “if this isn’t working we will just give you more potent steroids,” it states that there my need to be a reevaluation. Speak to your doctor about such matters because it is unbelievably important that you are diagnosed correctly. Perhaps you need a swab done to see if you have an infection? Or perhaps you are allergic to something inside the medication, or to a chemical or food you are use.

“In another study, Aclovate (alclometasone dipropionate) was applied to 80% of the body surface of a normal subjects twice daily for 21 days (3 weeks) with daily, 12 hour periods of whole body occlusion.” The HPA axis decreased 10% in these patients. This is a Class 6, mildly potent steroid, and within 3 weeks there was HPA axis suppression. First, 80% is almost full body, and some doctors will tell you to do that. Secondly, what is a normal subject? Someone with healthy skin? If so, someone with eczema will be even worse off since our skin barrier is damaged. Source

One of my favorite quotes is, “Topically applied Aclovate cream and ointment can be absorbed in sufficient amounts to produce systemic effects.” There is that word again: systemic. This Class 6, mildly potent steroid, can start affecting our adrenal glands. If a doctor says this isn’t true, hand them an insert.

This insert also says the same thing as Clobetasol Propionate regarding child toxicity and infection warnings. It also specified that it should not be used on diaper dermatitis.

“The following local adverse reactions have been reported…”

Who reports this? I never have. Where are these reports being made, or sent? Who sends them? Patients? Doctors? I know when I’ve stated adverse affects I’ve been told I was wrong by a doctor, so I know they weren’t reporting what I saw. I can only imagine that the list given is much smaller and/or incorrect due to lack of reporting.

But, check this out, you CAN do something: REPORT YOUR ADVERSE EFFECTS

Overall, there seems to be many unclear and unknown scientific facts about this steroid (most likely for all, but I can’t speak fairly on that since I have not read every single insert). Are we as patients supposed to be fine about this? When doctors tell us they are perfectly safe when we have concerns and see adverse affects, what evidence do they possess?

More research, management, and reporting must be done for the safety of patients.

Not Just A Dermatology Subject

Dermatologists are not the only ones allowed to prescribe topical steroids. Other persons whom prescribe these drugs are general practitioners, our family doctor. However, they are not specialized in this area. We already know some dermatologists push past the guidelines, but GPs are even less educated on steroids and all of their adverse effects if overprescribed or prescribed incorrectly.

In the FDA Evaluation and Research paper, they point out how our GPs can be truly hurting us. “… family physicians frequently prescribed betamethasone dipropionate and clotrimazole to children younger than 5 years of age and for use on genital skin disorders.”

Not only should this super potent steroid be prescribed with utmost caution to adults, but then add an anti-fungal (clotrimazole) into the mix, and you’ve got mega trouble. NEVER mix antifungals with topical steroids, and never use a steroid on a fungal infection. It is also stated in topical steroid inserts to never use these topical steroids on the genitals since it is extremely sensitive and most likely under occlusion (diaper).

This paper also talks heavily about research they constructed from 202 cases. The median age was 7 years old, a mix of both genders, and drum roll…. A median of topical steroid use for 169.3 days. That comes out to a little over 5.5 months of consecutive use. The shortest time was 1 day, and the longest was 7 years. This is why people have steroid phobia from this type of disregard for topical steroid guidelines.

If doctors wish to have the trust of their patient, then patients need to see that doctors can be trusted. We are the ones who have to endure the consequences. We are the ones who will have to suffer. There has to be open and honest communication on a level playing field. So many lives can be saved from needless pain if topical steroids were not only used strictly by a guideline (NOT by someone’s discretion), but also to know that the guideline set is correct and appropriate.

 

 

The Symptom Game

When you are sitting on your couch watching television, an advertisement may come up for a new drug. Pay attention when this happens. Listen to the commercial and take note of all the side effects that new drug may entail.

You decide you want to take that drug despite the risk. But, suddenly, you have two symptoms pop up. Your doctor says not to worry, there are drugs for those symptoms. Now, instead of one medication, you are taking three.

Then, one of your new medications is bringing on a side effect. Your doctor says don’t worry, there is a drug for that symptom. Now, instead of three medications, you are taking four.

This is how the world goes ’round. You went from one problem, to four.

Ever read the story about The Little Old Lady who Swallowed a Fly?

 

There was an Old Lady, who swallowed a fly.
But, I don’t know why, she swallowed the fly. 
Perhaps, she’ll die!
 
I know an Old Lady who swallowed a spider.
It wiggled and tickled and jiggled “inside her.
She swallowed the spider to catch “the fly.
But I don’t know why she swallowed the fly.
Perhaps, she’ll die!
 
I know an Old Lady who swallowed a bird.
How absurd – to swallow a bird!
She swallowed the bird to catch the spider
It wiggled and tickled and jiggled inside her.
She swallowed the spider to catch the fly. 
But I still don’t know why she swallowed the fly.
Perhaps, she’ll die!
 
I know an Old Lady who swallowed a cat.
Imagine that!  She swallowed a cat!
She swallowed the cat to catch the bird.
She swallowed the bird to catch the spider
It wiggled and tickled and jiggled inside her.
She swallowed the spider to catch the fly.
But I still don’t know why she swallowed the fly.
Perhaps, she’ll die!
 
I know an Old Lady who swallowed  a dog.
What a hog!  She swallowed a dog!
She swallowed a dog to catch the cat.
She swallowed the cat to catch the bird.
Swallowed the bird to catch the spider
It wiggled and tickled and jiggled inside her.
She swallowed the spider to catch the fly.
But I still don’t know why she swallowed the fly.
Perhaps, she’ll die!
 
I know an Old Lady who swallowed a goat.
It stuck in her throat, that silly old goat.
She swallowed the goat to catch the dog,
Swallowed the dog to catch the cat,
Swallowed the cat to catch the bird, 
Swallowed the bird to catch the spider 
It wiggled and tickled and jiggled inside her.
She swallowed the spider to catch the fly.
But I still don’t know why she swallowed the fly.
Perhaps, she’ll die!
 
I know an Old Lady who swallowed a cow.
I don’t know how she swallowed a cow.
But, she swallowed the cow to catch the goat,
Swallowed the goat to catch the dog,
Swallowed the dog to catch the cat,
Swallowed the cat to catch the bird,
Swallowed the bird to catch the spider
It wiggled and tickled and jiggled inside her.
She swallowed the spider to catch the fly.
But I still don’t know why she swallowed the fly.
Perhaps, she’ll die!
 
I know an Old Lady who swallowed a horse.
She’s DEAD, of course!

-Recorded by Dr. Mike Lockett 

 

Down the rabbit hole, further and further. Always weigh out if your first initial problem is worth potentially incurring many, many others.

How is this Legitimate?

This is the abstract from a review done in Australia on the effects of TCS in children.

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“… and their unfounded concerns…” Ya, you read that right. I’m quite concerned as to what they deem unfounded?

“Contrary to popular perceptions, (TCS) use in pediatric eczema does not cause atrophy, hypopigmentation, hypertrichosis, osteoporosis, purpura or telangiectasia when used appropriately as per guidelines.”

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Link for above article

It is well known that using topical steroids on children should be used with extreme caution, and if parents have questions or concerns, they didn’t just suddenly make them up in their head. No, they have undoubtedly heard things (that are likely founded) and have every right to be concerned. Often times, children even outgrow eczema. If their case is mild, there is no reason to start lathering them in topical steroids (in my personal opinion). Babies get rashes and skin blemishes. If they aren’t bothering the child or aren’t severe, perhaps finding a more natural way to deal with their skin would be best before jumping onto steroids.

A problem I also have with the “use appropriately as per guidelines” sentence is that doctors often stray from the said guidelines. If the product says to only use the drug a certain way and the doctor’s discretion is different, then there is a huge problem. No amount of “don’t worry” or “it’s totally safe” will in actuality make it safe for you to go past the 2 to 4 week rule in children. And, the larger the surface area you are told to put the steroid, the higher the potential of adverse effects (you know, those “unfounded” ones).

To further my proof, you can read the FDA Evaluation and Research paper.

Founded by three different references, it states, “… HPA axis suppression has been observed in infants and children with both high potency and low potency topical corticosteroids.” Why on earth would you put a child at an even higher risk with potent steroids when they should only be placed on the least potent steroid first, of which they could still risk having side effects if used over the guideline mark? For example, this evaluation states Fluticasone (Class 5 steroid), is said to be approved for patients 3 months old and up for a maximum of 4 weeks. Other studies show an even shorter period of 2 weeks should be utilized. The potent and super potent steroids are Class 1 and 2.

The best part of this research paper: “… the labeling of each product should advise practitioners of the appropriate duration of use of the product. The labeling should give information regarding how quickly improvement in dermatoses should occur after therapy with topical corticosteroid is started, and practitioners should be advised to discontinue the product if improvement does not occur within this time frame.”

It doesn’t say if the steroid isn’t working, immediately up their potency. It says DISCONTINUE. They need to be reassessed.This is what is supposed to happen.