Comparison of Topical Corticosteroids

Transcription

1 PL Detail-Document # This PL Detail-Document gives subscribers additional insight related to the Recommendations published in PHARMACIST S LETTER / PRESCRIBER S LETTER September 2012 Comparison of Topical Corticosteroids Potency of topical steroids is based on their skin vasoconstricting ability and ranked on a scale of I-VII. 1,2 Typically, drugs that rank I are classified as very high potency; II is considered high potency; III, IV, and V are medium potency; and VI and VII are low potency. 2,5 Classification can vary depending on the source, however, especially in the medium and high range. Furthermore, similar vasoconstricting ability does not indicate therapeutic equivalence. 1,3 The following chart compares topical corticosteroids available in the U.S. for treatment of dermatologic conditions based on potency, dose, dosage forms and sizes, and cost. Additional information pertinent to prescribing is provided. *Propylene glycol is added to optimize drug absorption in the augmented formulations. Very High Potency d Augmented* betamethasone dipropionate (Diprolene) Clobetasol propionate (Clobex, Olux, Olux-E, Temovate, Temovate E) Continued QD to QD (Shampoo) 0.05% Lotion (30, 60 ml) 0.05% Oint (15, 45, 50 gm) 0.05% Gel (15, 50 gm) 0.05% Cream (15, 30, 45, 60 gm) 0.05% Cream (emollient base) (15, 30, 60 gm) 0.05% Foam (50, 100 gm) 0.05% Gel (15, 30, 60 gm) 0.05% Lotion (60 ml, 120 ml) 0.05% Oint (15, 30, 45, 60 gm) 0.05% Scalp application (25, 50 ml) 0.05% Shampoo (118 ml) 0.05% Spray (60, 125 ml) 30 ml lotion ml lotion gm oint gm oint gm oint gm cream (emollient) gm cream (emollient) gm cream (emollient) gm cream gm cream gm cream gm cream gm gel gm gel gm gel It is recommended that patients on very high potency steroids not be discontinued abruptly; but instead switch to a lower potency agent. 3,7 Treatment duration for very high potency steroids should generally not exceed 2 to 4 weeks of continuous use because of the potential for systemic side effects. 3,e Total dose should generally not exceed 50 grams per week because of the potential for adrenal suppression. 3,e Continued

2 (PL Detail-Document #280908: Page 2 of 12) Very High Potency, continued Clobetasol propionate, continued Diflorasone diacetate Generic available Fluocinonide (Vanos) 15 gm oint gm oint gm oint gm oint ml scalp application ml scalp application ml shampoo ml spray (Clobex) ml spray (Clobex) ml lotion ml lotion gm foam gm foam QD to TID 0.05% Oint (15, 30, 60 gm) 15 gm oint gm oint gm oint QD to 0.1% Cream (30, 60, 120 gm) 30 gm cream gm cream gm cream Occlusive dressings can be used with caution with diflorasone diacetate and fluocinonide, but should be avoided with other very high potency agents, per FDAapproved labeling. Clobestasol may cause HPA axis suppression at doses as low as 2 gm daily. Lower potency agents are preferred for the face, groin, armpits, or skinfolds due to susceptibility to local side effects and systemic absorption. 1 Symptoms of adrenal suppression include weakness, weight loss, hypotension, and gastrointestinal distress. Halobetasol propionate (Ultravate) QD to 0.05% Cream (15, 50 gm) 0.05% Oint (15, 50 gm) 15 gm cream gm cream gm oint gm oint 75.99

3 (PL Detail-Document #280908: Page 3 of 12) High Potency d Amcinonide Augmented* betamethasone dipropionate (Diprolene AF) Betamethasone dipropionate Desoximetasone (Topicort) Diflorasone diacetate 0.1% Cream (15, 30, 60 gm) 0.1% Lotion (60 ml) 0.1% Oint (60 gm) 15 gm cream gm cream gm cream ml lotion gm oint % Cream (15, 50 gm) 15 gm cream gm cream QD to 0.05% Oint (15, 45 gm) 15 gm oint gm oint % Cream (15, 60, 100 gm) 0.05% Gel (15, 60 gm) 0.25% Oint (15, 60, 100 gm) 15 gm cream gm cream gm cream gm gel gm gel gm oint gm oint gm oint % Cream (15, 30, 60 gm) 15 gm cream gm cream gm cream Occlusive dressings should be avoided with betamethasone dipropionate, but can be used with caution with other high potency agents, per FDA-approved labeling. Lower potency agents are preferred for the face, groin, armpits, or skinfolds due to susceptibility to local side effects and systemic absorption. 1 Fluocinonide Continued to 0.05% Cream (15, 30, 60, 120 gm) 0.05% Gel (15, 30, 60 gm) 0.05% Oint (15, 30, 60 gm) 0.05% Solution (20, 60 ml) 15 gm cream gm cream gm cream gm cream gm gel 18.83

4 (PL Detail-Document #280908: Page 4 of 12) High Potency, continued Fluocinonide, continued 30 gm gel gm gel gm oint gm oint gm oint ml sol ml sol Halcinonide (Halog) Triamcinolone acetonide to 0.1% Cream (30, 60, 216 gm) 0.1% Oint (30, 60 gm) 30 gm cream gm cream gm cream gm oint gm oint % Oint (15 gm) 15 gm oint Medium Potency d Betamethasone dipropionate QD to (cream) (lotion) 0.05% Cream (15, 45, 50 gm) 0.05% Lotion (60 ml) 15 gm cream gm cream gm cream ml lotion 45 Medium or low potency agents are preferable when a large body surface area needs to be treated. 1 Betamethasone valerate (Luxiq) QD to TID (Luxiq) 0.1% Cream (15, 45 gm) 0.1% Oint (15, 45 gm) 0.12% Foam (50, 100 gm) 0.1% Lotion (60 ml) 15 gm cream gm cream gm oint gm oint gm foam (Luxiq) gm foam (Luxiq) ml lotion 72 Medium potency agents are generally well tolerated when used for three months or less on nonfacial, nonintertriginous areas. 1 Continued

5 (PL Detail-Document #280908: Page 5 of 12) Medium Potency, continued Clocortolone pivalate TID (Cloderm) Desoximetasone (Topicort LP) 0.1% Cream (30, 45, 75, 90 gm) 30 gm cream gm cream gm cream gm cream % Cream (15, 60, 100 gm) 15 gm cream gm cream gm cream Occlusive dressings should be avoided with betamethasone dipropionate and fluticasone propionate 0.05% cream per FDA-approved labeling. Fluocinolone acetonide TID to 0.025% Cream (15, 60 gm) 0.025% Oint (15, 60 gm) 15 gm cream gm cream gm oint gm oint Fluocinonide (emulsified base) to 0.05% Cream (15, 30, 60 gm) 15 gm cream gm cream gm cream Flurandrenolide (Cordran, Cordran SP) 0.05% Cream (15, 30, 60 gm) 0.05% Lotion (15, 60, 120 ml) 15 gm cream gm cream gm cream ml lotion ml lotion ml lotion 690 QD to 4 mcg/cm 2 tape (7.5 cm x 60 cm tape, 7.5 cm x 200 cm tape) 7.5 cm x 60 cm cm x 200 cm

6 (PL Detail-Document #280908: Page 6 of 12) Medium Potency, continued Fluticasone propionate (Cutivate) QD to 0.05% Cream (15, 30, 60 gm) 15 gm cream gm cream gm cream % Oint (15, 30, 60 gm) 15 gm oint gm oint gm oint QD 0.05% Lotion (60, 120 ml) 60 ml (Cutivate) ml (Cutivate) Hydrocortisone butyrate (Locoid, Locoid Lipocream) Hydrocortisone valerate (Westcort) (lotion) 0.1% Cream (15, 45 gm) Lipocream (15, 45, 60 gm) 0.1% Oint (15, 45 gm) 0.1% Sol (20, 60 ml) 0.1% Lotion (60, 120 ml) 0.2% Cream (15, 45, 60 gm) 0.2% Oint (15, 45, 60 gm) 15 gm cream gm cream gm cream (Locoid Lipocream) gm cream (Locoid Lipocream) gm cream (Locoid Lipocream) ml lotion (Locoid) ; 118 ml lotion (Locoid) gm oint gm oint ml sol ml sol gm cream gm cream gm cream gm oint gm oint gm oint

7 (PL Detail-Document #280908: Page 7 of 12) Medium Potency, continued Mometasone furoate QD (Elocon) 0.1% Cream (15, 45 gm) 0.1% Oint (15, 45 gm) 0.1% Lotion (solution) (30, 60 ml) 15 gm cream gm cream ml lotion ml lotion gm oint gm oint Prednicarbate (Dermatop) 0.1% Cream (15, 60 gm) 0.1% Oint (15, 60 gm) 15 gm cream gm cream gm oint gm oint Triamcinolone acetonide (Kenalog) Continued to TID to (Spray) (0.1% lotion) 0.025% Cream (15, 80, 454 gm) 0.025% Lotion (60 ml) 0.025% Oint (15, 80, 454 gm) 0.1% Cream (15, 30, 80, 454 gm) 0.1% Lotion (60 ml) 0.1% Oint (15, 80, 454 gm) 0.147% Spray (63, 100 gm) 15 gm cream gm cream gm cream ml lotion gm oint gm oint gm oint gm cream gm cream gm cream gm cream ml lotion gm oint gm oint gm oint gm spray (Kenalog) gm spray (Kenalog)

8 (PL Detail-Document #280908: Page 8 of 12) Medium Potency, continued Triamcinolone acetonide, to continued 0.5% Cream (15 gm) 15 gm cream Low Potency d Alclometasone dipropionate (Aclovate) 0.05% Cream (15, 45, 60 gm) 0.05% Oint (15, 45, 60 gm) 15 gm cream gm cream gm cream gm oint gm oint gm oint Hydrocortisone is available by prescription and OTC. The 2.5% strength is prescription. Some 1% formulations are prescription while others are OTC. Desonide (Desonate, DesOwen, Verdeso) (Foam, Gel) 0.05% Cream (15, 60 gm) 0.05% Foam (50, 100 gm) 0.05% Lotion (60, 118 ml) 0.05% Oint (15, 60 gm) 0.05% Gel (60 gm) 15 gm cream gm cream gm foam (Verdeso) gm foam (Verdeso) gm gel (Desonate) ml lotion ml lotion gm oint gm oint Consider low potency agents for children, pregnant women, the elderly, and patients with large areas to be treated. 1 Low potency agents are preferred for the face, groin, armpits, or skinfolds due to susceptibility to local side effects and systemic absorption. 1

9 (PL Detail-Document #280908: Page 9 of 12) Low Potency, continued Fluocinolone acetonide (Capex, Derma- Smoothe/FS) QD (Shampoo) TID to (Cream, Solution) TID (Oil) 0.01% Cream (15, 60 gm) 0.01% Shampoo (120 ml) 0.01% Sol (60 ml) 0.01% Oil (118 ml) 15 gm cream gm cream ml shampoo (Capex) ml sol ml oil Hydrocortisone OTC up to 0.5% Cream (28, 56 gm) 0.5% Oint (38.3 gm) 56 gm cream 4.49 (retail price) (AWP not available) Hydrocortisone (Cortaid, Cortizone-10) Some products OTC up to 1% Cream (28, 56, 454 gm) 1% Oint (28, 454 gm) 28 gm cream 3.49 (retail price) 56 gm cream 6.49 (retail price) 454 gm cream 40 (retail price) (AWP not available) Hydrocortisone, continued to 2.5% Cream (20, 28, 30, 454 gm) 2.5% Oint (20, 28.3, 454 gm) 2.5% Lotion (60, 120 ml) (AWP not available)

10 (PL Detail-Document #280908: Page 10 of 12) Low Potency, continued Hydrocortisone acetate U-cort Some available OTC to 1% Cream (15, 20, 30 gm) 1% Oint (30 gm) 30 gm cream gm oint 3.99 a. Dosing interval per FDA-approved product labeling. Once or twice daily dosing is generally recommended. 1,3,6,7 For psoriasis, some experts start with dosing, then taper as the disease responds. Once daily dosing of medium to very high potency agents helps minimize side effects. 4 Even less frequent dosing (e.g., weekend only) may be appropriate for chronic conditions such as psoriasis or eczema once the disease is under control. 1,3,7 b. Fingertip units can be used to estimate the quantity of topical corticosteroid the patient will need. A fingertip unit is the amount squeezed from the tube from the tip of the finger to the first joint. It s approximately 500 mg. It will take three fingertip units to cover the scalp; 2.5 for the face and neck; one for the elbows, knees, or an entire hand; four for an arm (including entire hand) or the buttocks; 1.5 for both soles or one foot (including toes); eight for a leg (including entire foot), back of trunk, or front of trunk; and 0.5 for the genitalia. c. Patients may need more than one product for use on different body parts; for use for disease of varying severity; or for tapering. d. Potency classification based on product labeling and references 2, 5, 6, and 8. e. Treatment duration and maximum total dose per week may vary per individual product labeling. Abbreviations: QD = once daily; = twice daily, TID = three time daily; = four times daily U.S. product labeling used for the above chart: Aclovate (April 2011); Ala-Scalp (September 2011); amcinonide cream, ointment (February 2010 [Taro]); amcinonide lotion (November 2011 [Fougera]); ApexiCon E (October 2011); betamethasone dipropionate cream, lotion, ointment (October 2011 [Fougera]); betamethasone dipropionate gel, augmented (October 2003 [Taro]); betamethasone dipropionate ointment (February 2006 [Actavis]); betamethasone valerate cream, ointment, lotion (September 2011 [Fougera]); Capex (February 2007); clobetasol propionate gel, cream, ointment (March 2010 [Taro]); clobetasol propionate emollient cream (September 2004 [Taro]); Clobex lotion (October 2005); Clobex shampoo (November 2011); Clobex spray (January 2011); Cloderm (July 2007); Cordran lotion (July 2011); Cordran SP (February 2006); Cordran tape (November 2011); Cortaid cream (November 2010); Cortaid ointment (October 2009); Cutivate lotion (October 2011); Derma-Smoothe/FS (March 2012); Dermatop cream (October 2011); Dermatop ointment (January 2011); Desonate (December 2009); DesOwen (June 2008); diflorasone diacetate cream (February 2006 [Taro]); diflorasone diacetate ointment (February 2006 [Taro]); Diprolene lotion (August 2010); Diprolene ointment (August 2010); Diprolene AF (August 2010); fluocinolone acetonide cream (October 2011 [Fougera]); fluocinolone acetonide ointment (October 2011 [Fougera]); fluocinolone acetonide solution (October 2011 [Fougera]); fluocinonide cream, emulsified base, gel, ointment (April 2010 [Taro]);

11 (PL Detail-Document #280908: Page 11 of 12) fluocinonide solution (October 2011 [Taro]); fluticasone propionate cream (August 2011 [Fougera]); fluticasone propionate ointment (February 2012 [Fougera]); Halog (June 2009); hydrocortisone 0.5% cream (November 2011 [Fougera]); hydrocortisone 0.5% ointment (December 2011 [Fougera]); hydrocortisone 2.5% lotion (November 2011 [Fougera]); hydrocortisone 2.5% cream, ointment (December 2011 [Fougera]); hydrocortisone butyrate cream, ointment, solution (February 2010 [Taro]); hydrocortisone valerate (May 2011 [Taro]); Kenalog spray (August 2011); Locoid Lipocream (October 2009); Locoid lotion (July 2008); Luxiq (November 2009); mometasone furoate cream (December 2011 [Fougera]); mometasone furoate lotion (December 2011 [Fougera]); mometasone furoate ointment (January 2012 [Fougera]); Olux (March 2011); Olux-E (June 2011); Temovate scalp application (October 2008); Topicort cream, gel (September 2011); Topicort ointment (October 2010); triamcinolone acetonide cream (September 2011 [Fougera]); triamcinolone acetonide lotion (October 2011 [Fougera]); triamcinolone acetonide 0.025% and 0.1% ointment (October 2011 [Fougera]); triamcinolone acetonide cream (August 2009 [Perrigo]); triamcinolone acetonide ointment (August 2009 [Perrigo]); U-cort (October 2010); Ultravate (March 2012); Vanos (March 2012); Verdeso (August 2011) Users of this PL Detail-Document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations. Information and internet links in this article were current as of the date of publication.

12 (PL Detail-Document #280908: Page 12 of 12) Project Leader in preparation of this PL Detail- Document: Melanie Cupp, Pharm.D., BCPS References 1. Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for the use of topical glucocorticoids. J Am Acad Dermatol 1996;35: National Psoriasis Foundation. Topical steroids potency chart. (Accessed August 11, 2012). 3. Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. J Am Acad Dermatol 2009;60: Shear N, Vender R, Thomas R, Kuehl BL. Eczema treatment. Skin Therapy Lett. Last modified June 27, html. (Accessed August 11, 2012). 5. Fougera. Knowledge center: steroid potency comparison. ency.asp. (Accessed August 12, 2012). 6. Herrier SN. Dermatotherapy and drug-induced skin disorders. In: Aldredge BK, Corelli RL, Ernst ME, et al, editors. Koda-Kimble and Young s Applied Therapeutics: the clinical use of drugs. 10 th ed. Philadelphia, PA: Lippincott Williams & Wilkins; p Haber RM. Topical management of recalcitrant psoriasis and eczema. Skin Therapy Lett FP 2010;6(3): ecps [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2012. Corticosteroids: topical. CPhA monograph (November 2011). (Accessed August 13, 2012). Cite this document as follows: PL Detail-Document, Comparison of Topical Corticosteroids. Pharmacist s Letter/Prescriber s Letter. September Evidence and Recommendations You Can Trust 3120 West March Lane, P.O. Box 8190, Stockton, CA ~ TEL (209) ~ FAX (209) Subscribers to the Letter can get PL Detail-Documents, like this one, on any topic covered in any issue by going to or