The most common side effect of topical corticosteroid use is skin atrophy. All topical steroids can induce atrophy, but higher potency steroids, occlusion, thinner skin, and older patient age increase the risk. The face, the backs of the hands, and intertriginous areas are particularly susceptible. Resolution often occurs after discontinuing use of these agents, but it may take months. Concurrent use of topical tretinoin (Retin-A) % may reduce the incidence of atrophy from chronic steroid applications. 30 Other side effects from topical steroids include permanent dermal atrophy, telangiectasia, and striae.
Conditions which augment systemic absorption include the application of the more potent steroids, use over large surface areas, prolonged use, and the addition of occlusive dressings. Therefore, patients receiving a large dose of a potent topical steroid applied to a large surface area or under an occlusive dressing should be evaluated periodically for evidence of HPA axis suppression by using the urinary free cortisol and ACTH stimulation tests. If HPA axis suppression is noted, an attempt should be made to withdraw the drug, to reduce the frequency of application, or to substitute a less potent steroid.
Pruritus that is refractory to moisturizers and conservative measures can be treated with antihistamines or tricyclic antidepressants. Compared with the newer, nonsedating histamines, the older, sedating agents such as hydroxyzine (Atarax) and diphenhydramine (Benadryl) are more effective in controlling pruritus. 20 However, these agents can affect a child's ability to learn or an adult's ability to drive and work. 21 If drowsiness is a problem, a nonsedating antihistamine can be tried to see if it is effective. Tricyclic antidepressants such as doxepin (Sinequan) and amitriptyline (Elavil) also have an antihistaminic effect, induce sleep and reduce pruritus. 22