Side effects of topical corticosteroids and their prevention

The goal of topical corticosteroid therapy is to maximise the clinical benefits of this highly effective group of drugs, while minimising their adverse effects. Many types of steroid-induced skin lesions and skin atrophy can occur by such mechanisms as the suppression of cell proliferation, immunosuppression, or hormonal activity, and a trend towards an increased incidence of steroid-induced dermatological disturbances has been observed in recent years. Systemic effects have also been documented. To reduce the risk of local and systemic effects, it is necessary to consider factors such as the intrinsic potency of a drug, type of vehicle used and frequency of application. A potent drug may be changed to a less potent one, or the dosage reduced. Once-daily application is often as effective as three-times-daily application, and intermittent application can also be recommended. The concept of an 'ante-drug' promises new developments in topical corticosteroid therapy. An 'ante-drug', e.g. difluprednate, has potent efficacy but fewer side effects than conventional therapy, since it acts at the application site and then is metabolised to less active or inactive compounds before reaching the systemic circulation. It is likely that future corticosteroids will have the attributes of an ante-drug, thus greatly reducing the risk of systemic effects. At present, however, it is still necessary to recognise the influence of various drug and patient factors that contribute to side effects, in order to balance clinical efficacy with an acceptable side effect profile.