Aug 18, 2022

TRANSCRIPT

Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Michelle Tarbox. I'm an academic dermatologist at TexasTechUniversityHealthSciencesCenter, in beautiful, sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hello, everybody. This is Dr. Luke Johnson. I'm a pediatric dermatologist and a general dermatologist with the University of Utah.

Dr. Tarbox: So today we're going to talk about topical steroids. Luke, what are topical steroids?

Dr. Johnson: Well, they're a topical medication, and the type of medication they are is a steroid.

Dr. Tarbox: : Ba da bum bum!

Dr. Johnson: I know, right? Topical is something you put on the skin. So sometimes you can think of it as I put it on top of my skin. So it's topical. It's not tropical. That would be palm tree-derived medicine.

So a steroid is a specific type of molecule. And I don't think the exact biochemistry of the molecule is all that important. But what is important is that this molecule goes into your cells and affects the way the cells express their genes. There are some kinds of steroids that the body makes, all the sex hormones, like estrogen and testosterone are steroids. And the body also makes a type of steroid called a corticosteroid, which is sort of an anti-inflammatory stress molecule. And we take advantage of the anti-inflammatory properties to make corticosteroids in our medications. So even though, like, testosterone is a steroid, when dermatologists say "topical steroids," we're not talking about topical testosterone, we're talking about topical corticosteroids.

Dr. Tarbox: And sometimes my patients, when I say the word "steroid," they'll think about, you know, oh, a big muscle man. And I always tell them this is not the kind of bodybuilding. And then I pose because, of course, steroids. We're not going to make your pose sicker. We're just going to make your skin less inflamed.

And you mentioned that that's really the side effect we're taking advantage of, of these medications. So the reason we love to use these, when they're necessary, is because they work against inflammation. And many problems we run into in the skin are inflammatory. And as dermatologists or patients who are treating a skin-related condition, we're all lucky that the organ we're treating is right there under our fingertips. It's literally accessible to us all the time. So it's easy to put medication on the organ that's having the problem. What about their safety Luke?

Dr. Johnson: Well, the good news is they are very safe. The body makes its own steroids. So we're putting on steroids, something that the body can make itself. We can use them in pregnancy. We could use them in breastfeeding and children and babies. I mean, they're not completely without risks, because neither is anything, eating avocados isn't completely without risk, but they are extremely safe.

One of the benefits, as well, is that there are no interactions with other medicines that you could be taking, right? You're putting it on your skin. So it's not like taking a pill that could interfere with some other things. And also unlike taking a pill, they don't have those potential side effects that you might get if you were to take a pill by mouth. So dermatologists love our topical steroids.

Dr. Tarbox: It's definitely not the only medication we use, and there are other topical medications we use as well. But one of the benefits of topical steroids is they tend to be relatively quick, relatively well tolerated. There is a variety of strengths and vehicles. So most people can find a preparation they can use and tolerate. And they range from a gel to a solution, to a lotion, to a cream, all the way down to an ointment, which is very thick, greasy medication with no extra water in it. So that actually often will allow you to spare the use of some preservatives and some patients are allergic to those. So those can be very good choices for that.

And in general, they're relatively inexpensive. One issue I think all physicians run into, when taking care of their patients, is considering the cost of the medication for the patient. Are they going to be able to get that medication? It could be the perfect fit medicine for their condition, but if they can't get it in their hands to use it, it doesn't do them any good. So medications that are reasonably priced for our patients are things that we have to think about.

What are some things we don't like as much about topical steroids, Luke?

Dr. Johnson: Before I talk about that, I want to mention that you said that they come in various strengths and what we call vehicles, which are is it a cream or an ointment or a gel or whatever. So if you wanted to try out a topical steroid on your own for some inflammatory skin condition that you have, like a mosquito bite, for example, you can just go to the grocery store or the drugstore and buy one.

Hydrocortisone is generally the one that's available over-the-counter, at least here in the United States. And it's usually a 1% preparation. It's very weak, but it could be strong enough for, you know, a mild insect bite or something like that. But it's so weak that really I don't think you have to worry too much about the side effects. It's best as an ointment. Ointments tend to have better delivery into the cells. So you want to find a nice gloopy ointment hydrocortisone 1%. It's a really good thing to start with if you're trying to treat something on your skin that is itchy. And remember very weak, you could probably put it on twice a day forever and never have a problem with it.

Dr. Tarbox: So what are some of the things that cause problems with topical steroids?

Dr. Johnson: Well, they can be annoying. They might feel greasy or unpleasant. But you might be able to find a better vehicle if they did feel that way. And if they are kind of greasy, they might get on stuff, like they might get on your clothes or your furniture or your pets, I guess, you know, especially stuff that's an ointment doesn't really rub in very well sometimes even though it works well.

You might have a hard time knowing how much to use. You know, it's not like a pill where there's the dose. So some people might put on a tiny, tiny little bit, and some people might put on a huge glob. In general, you need just an amount to cover the area with a thin film of medicine.

Also, if you have a lot of affected skin, it might just be a pain to try to put it on everywhere. You know, we see patients who have eczema or psoriasis or other conditions, where it affects 40% or 50% of their body. I don't think we can expect them to be slathering medicine on that much of their body twice a day, every day.

Dr. Tarbox: I agree. That's a lot of ground to cover. You know, when you're talking about applying these topical steroids, I think that, you know, some people get very nervous about using these. And one of the things that we try to emphasize as dermatologists is that the way that we use these medicines for limited periods of time on areas that are specifically inflamed is less likely to cause problems. And side effects for topical steroids is actually quite rare. What are things we need to look over for?

Dr. Johnson: The side effects are rare, but they do happen. And I have seen them, and I feel bad when one of my patients gets one of these side effects. Though I assume every doctor feels bad if their patients get side effects from their medicines, whether they're topical steroids or something else.

I do like to emphasize that as long as you're putting it on a rash, you are unlikely to get into trouble. However, if you've been putting it on that rash for two weeks and nothing has happened, then probably it's not working. And just continuing to put it on isn't going to get you any better and might give you side effects. If you've been putting it on for two weeks and it's getting better, well, then you might continue doing it until the rash is gone. Or if it's not gone in two weeks, maybe it's time to talk to your dermatologist and make sure you're using the right medicine.

But side effects that can exist are more likely if they're placed on certain types of skin. So thin skin, like the skin of the face is thinner than the skin of the back, more likely to have side effects. Skin that is often occluded, meaning there's other stuff covering it, like your clothes, for example, like right on the waistline where your waistband will be pressing against that medicine and pushing it into your skin, increased risk of side effects there. Similarly, if there's areas where skin touches skin, like in your armpits, for example, again, pushing that medicine into the skin, increasing the effect of the medicine, which also increases the side effect.

Using them without medical advice. So again, over-the-counter hydrocortisone, very safe, but in this day and age, you can probably find stronger steroids on the internet. You probably shouldn't be using those without medical advice, so look out for those.

And also I find that the vast majority of my patients and their parents underuse the medications because they're worried about side effects rather than overuse them and get side effects, because there seems to be a lot of misinformation about there claiming that the medicines are quite unsafe and scary and, you know, on a baby don't use them for more than three days in a row or something, which is completely made up. So one thing to look out for is don't be scared off by stuff that you read on the internet. Get medical advice from people who know.

Dr. Tarbox: Yes, absolutely. And, you know, the side effects that we can see tend to be skin limited in most cases. So the one we talk about the most is that atrophy of the skin or skin thinning. Where I see this most commonly is where people have misunderstood the instructions and are using the topical steroid as a moisturizer, generally applying it over large areas of skin, instead of focusing it on the areas of the rash. So that's an area of potential danger.

We do talk about steroid rebound, which means that when you take the medicine away, people can have sort of return of the eruption with some vengeance. That's relatively rare with most conditions, but it can occasionally occur. And especially in some areas, like the face or the chest or back, topical steroids may induce some acne or folliculitis or some rosacea-type symptoms. So we always have to balance the risk of that with the topicals that we choose.

So with all these complications with topicals, why don't we just use some oral steroids, Luke?

Dr. Johnson: So there's different ways to deliver steroids to the entire body. Probably the most common is by taking pills, though you can get shots as well that affect the whole body. We call these sorts of medicine systemic medicines. That means they affect the whole body. There's a lot more potential side effects with systemic steroids than with topical steroids. Some people need them, and those side effects are more dangerous the longer you take them. So some people have conditions for which they need to take steroids for months and months or even years and years.

Some of the side effects include things like high blood pressure, high blood sugar, difficulty sleeping. Some people can feel a little crazy on them. And then you can gain weight. And there can be problems with the eyes or the bones.

There's a lot of potential problems with systemic steroids. So a lot of reasons to like topical steroids, especially since we're putting them directly on our organ of interest. It's a good thing I'm not a heart doctor because I'd always be tempted to reach into the patient's chest and put medicine on the heart.

Dr. Tarbox: So in general, we like our patients to understand that these medications can be very helpful when used properly and can also be quite safe. So, of course, you want to use them under the direction of your physician, and you want to ask if you have any questions or concerns.

Dr. Johnson: That is all for today. Thanks for hanging out with us and learning about topical steroids. Thanks to the University of Utah for supporting the podcast, and thanks to Texas Tech for lending us Michelle. And if you're a super dermatology nerd, like we are, maybe you would like to come hang out with us on our other podcast.

Dr. Tarbox: We have another podcast called "Dermasphere." That is the podcast by dermatologists for dermatologists and for the dermatologically curious. It is available wherever you get your podcasts. We also have social media profiles, and you can check us out on dermaspherepodcast.com.

Dr. Johnson: We'll see you guys next time. Stay healthy.