Comparison of Topical Corticosteroids

PL Detail-Document #280908 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 57.23 60 ml lotion 112.77 15 gm oint 30 45 gm oint 127.71 50 gm oint 73 15 gm cream (emollient) 27.50 30 gm cream (emollient) 42.35 60 gm cream (emollient) 69 15 gm cream 24.71 30 gm cream 35.86 45 gm cream 50.21 60 gm cream 64.17 15 gm gel 27.75 30 gm gel 40.69 60 gm gel 74.16 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

(PL Detail-Document #280908: Page 2 of 12) Very High Potency, continued Clobetasol propionate, continued Diflorasone diacetate Generic available Fluocinonide (Vanos) 15 gm oint 24.71 30 gm oint 35.86 45 gm oint 50.21 60 gm oint 64.17 25 ml scalp application 20.55 50 ml scalp application 39.60 118 ml shampoo 385.29 60 ml spray (Clobex) 332.56 125 ml spray (Clobex) 598.25 60 ml lotion 288.96 120 ml lotion 528.56 50 gm foam 169.86 100 gm foam 313.14 QD to TID 0.05% Oint (15, 30, 60 gm) 15 gm oint 37.56 30 gm oint 51.86 60 gm oint 100.16 QD to 0.1% Cream (30, 60, 120 gm) 30 gm cream 220.43 60 gm cream 379.80 120 gm cream 721.62 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 31.49 50 gm cream 75.72 15 gm oint 31.59 50 gm oint 75.99

(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 26 30 gm cream 38.88 60 gm cream 66.50 60 ml lotion 162.86 60 gm oint 194.40 0.05% Cream (15, 50 gm) 15 gm cream 36.43 50 gm cream 81.65 QD to 0.05% Oint (15, 45 gm) 15 gm oint 50.45 45 gm oint 87.01 0.25% Cream (15, 60, 100 gm) 0.05% Gel (15, 60 gm) 0.25% Oint (15, 60, 100 gm) 15 gm cream 57.63 60 gm cream 197.03 100 gm cream 224.95 15 gm gel 87.57 60 gm gel 280.20 15 gm oint 92.39 60 gm oint 243.06 100 gm oint 314.82 0.05% Cream (15, 30, 60 gm) 15 gm cream 70.51 30 gm cream 141.03 60 gm cream 282.07 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 3.56 30 gm cream 4.62 60 gm cream 6.90 120 gm cream 43.74 15 gm gel 18.83

(PL Detail-Document #280908: Page 4 of 12) High Potency, continued Fluocinonide, continued 30 gm gel 38.90 60 gm gel 38.68 15 gm oint 6.54 30 gm oint 9.51 60 gm oint 13.02 20 ml sol 47.98 60 ml sol 14.70 Halcinonide (Halog) Triamcinolone acetonide to 0.1% Cream (30, 60, 216 gm) 0.1% Oint (30, 60 gm) 30 gm cream 124.51 60 gm cream 211.73 216 gm cream 582.26 30 gm oint 124.51 60 gm oint 211.73 0.5% Oint (15 gm) 15 gm oint 10.10 Medium Potency d Betamethasone dipropionate QD to (cream) (lotion) 0.05% Cream (15, 45, 50 gm) 0.05% Lotion (60 ml) 15 gm cream 35.64 45 gm cream 71.28 50 gm cream 85.34 60 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 14.26 45 gm cream 29.11 15 gm oint 20.89 45 gm oint 42.66 50 gm foam (Luxiq) 223.07 100 gm foam (Luxiq) 415.19 60 ml lotion 72 Medium potency agents are generally well tolerated when used for three months or less on nonfacial, nonintertriginous areas. 1 Continued

(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 141.66 45 gm cream 212.48 75 gm cream 354.14 90 gm cream 424.97 0.05% Cream (15, 60, 100 gm) 15 gm cream 62.43 60 gm cream 231.49 100 gm cream 195.09 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 33.77 60 gm cream 101.27 15 gm oint 33.77 60 gm oint 101.27 Fluocinonide (emulsified base) to 0.05% Cream (15, 30, 60 gm) 15 gm cream 19.90 30 gm cream 27.50 60 gm cream 44.73 Flurandrenolide (Cordran, Cordran SP) 0.05% Cream (15, 30, 60 gm) 0.05% Lotion (15, 60, 120 ml) 15 gm cream 108 30 gm cream 186 60 gm cream 358.80 15 ml lotion 108 60 ml lotion 358.80 120 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 123.35 7.5 cm x 200 cm 264.67

(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 22.18 30 gm cream 34.18 60 gm cream 53.88 0.005% Oint (15, 30, 60 gm) 15 gm oint 22.25 30 gm oint 34.30 60 gm oint 54.10 QD 0.05% Lotion (60, 120 ml) 60 ml (Cutivate) 126.72 120 ml (Cutivate) 779.70 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 19.69 45 gm cream 42.25 15 gm cream (Locoid Lipocream) 85.76 45 gm cream (Locoid Lipocream) 244.94 60 gm cream (Locoid Lipocream) 326.59 59 ml lotion (Locoid) 237.06; 118 ml lotion (Locoid) 466.20 15 gm oint 10.52 45 gm oint 22.38 20 ml sol 9.80 60 ml sol 14.88 15 gm cream 15.25 45 gm cream 32.15 60 gm cream 38.70 15 gm oint 74.61 45 gm oint 150.42 60 gm oint 180.93

(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 26.75 45 gm cream 49 30 ml lotion 28.95 60 ml lotion 55.45 15 gm oint 23.90 45 gm oint 43.77 Prednicarbate (Dermatop) 0.1% Cream (15, 60 gm) 0.1% Oint (15, 60 gm) 15 gm cream 23.08 60 gm cream 56.76 15 gm oint 30 60 gm oint 73.79 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 4.45 80 gm cream 10.11 454 gm cream 22.73 60 ml lotion 37.79 15 gm oint 6.12 80 gm oint 11.15 454 gm oint 31.51 15 gm cream 5.58 30 gm cream 9.65 80 gm cream 12.68 454 gm cream 30 60 ml lotion 42.42 15 gm oint 5.57 80 gm oint 12.68 454 gm oint 30 63 gm spray (Kenalog) 195.88 100 gm spray (Kenalog) 310.92

(PL Detail-Document #280908: Page 8 of 12) Medium Potency, continued Triamcinolone acetonide, to continued 0.5% Cream (15 gm) 15 gm cream 11.10 Low Potency d Alclometasone dipropionate (Aclovate) 0.05% Cream (15, 45, 60 gm) 0.05% Oint (15, 45, 60 gm) 15 gm cream 19.05 45 gm cream 39.72 60 gm cream 50.30 15 gm oint 20 45 gm oint 39.70 60 gm oint 50.32 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 12.10 60 gm cream 27.81 50 gm foam (Verdeso) 194.92 100 gm foam (Verdeso) 364.25 60 gm gel (Desonate) 383.10 60 ml lotion 146.06 118 ml lotion 216.25 15 gm oint 15.45 60 gm oint 40.15 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

(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 44.57 60 gm cream 133.67 120 ml shampoo (Capex) 375.88 60 ml sol 90 118 ml oil 31.47 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)

(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 3.20 30 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]);

(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.

(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;35:615-9. 2. National Psoriasis Foundation. Topical steroids potency chart. http://www.psoriasis.org/page.aspx?pid=469. (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;60:643-59. 4. Shear N, Vender R, Thomas R, Kuehl BL. Eczema treatment. Skin Therapy Lett. Last modified June 27, 2012. http://www.skintherapyletter.com/treat/eczema/index. html. (Accessed August 11, 2012). 5. Fougera. Knowledge center: steroid potency comparison. http://www.fougera.com/knowledge_center/steroidpot 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; 2012. p. 925-43. 7. Haber RM. Topical management of recalcitrant psoriasis and eczema. Skin Therapy Lett FP 2010;6(3):1-4. 8. ecps [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2012. Corticosteroids: topical. CPhA monograph (November 2011). http://www.e-therapeutics.ca. (Accessed August 13, 2012). Cite this document as follows: PL Detail-Document, Comparison of Topical Corticosteroids. Pharmacist s Letter/Prescriber s Letter. September 2012. Evidence and Recommendations You Can Trust 3120 West March Lane, P.O. Box 8190, Stockton, CA 95208 ~ TEL (209) 472-2240 ~ FAX (209) 472-2249 Subscribers to the Letter can get PL Detail-Documents, like this one, on any topic covered in any issue by going to www.pharmacistsletter.com, www.prescribersletter.com, or www.pharmacytechniciansletter.com