How do the topical steroids work?

Okay. So these are all really good questions. And, you know, we don’t have very good answers to all of them. Topical steroids are quite kind of- they work in lots of different ways. So it’s not a very sophisticated targeted treatment, but we know that they reduce inflammation. We know that when they’re used on the skin, there’s very minimal absorption. So, you know, they’re safe to be used on the skin. We know that they’re very effective in eczema, we’ve got lots and lots of studies which show the benefits of topical steroids far outweigh any risks. And there are risks to using the wrong strength of steroid for the wrong amount of time in the wrong body area. But mostly, your doctors or dermatologists will advise you sensibly to use the right strength topical steroid. And if anything, we’re probably moving towards using slightly more potent corticosteroids topically, to try and keep the inflammation well controlled, rather than using inappropriately weak ones which never get it under control. So how they work is complex. But we do know that they do work, and that they’re safe to use.

So, corticosteroids do come in lots of different potencies and strengths, and they have lots of different names. But, you know, it can be quite confusing I think for different people. So it’s best if you have a kind of plan which shows, tells you which one you’re going to be using. Often we use a different one for the face than all the rest of the body, just because the skin is thinner on the face. Most people we find under-use their corticosteroid treatment, rather than over use it. And it’s very unusual to see side effects from the use of corticosteroids, because I think people are quite cautious, often overly cautious, with their use. So we would normally use a moderate to potent corticosteroid on the body, to control eczema. And we’d use it once a day. And most of them, they all need to be used really just once a day, for one to two weeks. And then we do something called proactive treatment. So we treat the flare-prone areas with weekend use of these corticosteroids to try and keep the activity of the eczema down. Because know that even when you’re not seeing eczema, there’s a lot inflammation in the skin. And so we, you know, by knowing this, we know that we have to treat those flare-prone areas regularly for some time in some people.

We would use, normally use a mild to moderate for the face. And, you know, with the eyelids, can be particularly- they are, you know, one area that you do probably need to be a little bit cautious about is around the eyes. And that’s where we might use something like Protopic, or tacrolimus, topically to those areas. Which is a non-steroid anti-inflammatory, which works on the inflammation of eczema as well.

And I like to stock up on my cream, especially the steroid because I went to the medical centre two weeks ago cos it was really bad. And they prescribed me a steroid cream. And I went to Superdrug cos that’s the closest pharmacist. They said that they didn’t have it because it was a global manufacturing problem and they have not had it for months. So I went to Boots and they said the same. So I had to go back to the medical centre and get a different prescription. And then, she said, the woman at Superdrug said, I was lucky, because I got the last ones that they had. So I try and use it, I try and not use it, but I try and stock up because you never know when the creams are going to run out.

Has that happened to you before, where creams that you have been using and getting on quite well with have, they’ve stopped producing them or they are just not available?

No, I mean, sometimes I have to wait like a couple of days for them to order it and get it in. Maybe sometimes they will just give me a smaller amount for time until they give me the full amount. But I’ve never had it where it’s been like a manufacturing problem and they can’t make it any more, which is kind of sad because the steroid cream I was wanting to use I know has worked in the past. But I’ve got another one now, so that’s alright. [Laughs].

One example is, there’s a cream called Fucibet that, when I was young I was prescribed to a lot, when my eczema was really bad, and I still insist upon getting it every time I go to the doctors. I really don’t like using any other certain ointments or steroid creams. And it’s because I’ve used it before; I know to the extent it works, but the doctor’s sort of argument is that apparently such creams have a negative effect, such as a skin thinner, as it may thin my skin that, to which I always argue to a doctor I would rather have slightly more thinner skin than have to deal with eczema. But the other issue with that is doctordoctors have also said that long term use of a certain steroid will sort of decrease its impact which may or may not be true but I’ve heard from doctors that if I use a certain cream consistently enough it’ll get to a point my body will reject it, it won’t make much of a difference to work for eczema.

And obviously I can’t argue it against the medical professional who obviously has like a sort of degree and Masters in their field, and I really don’t have any sort of merit to ponder about those questions.

I’ve used hydrocortisone and I’ve used it on my face and I’ve used it on my body. And I’ve been told by some doctors that like I can never use it on my face, like it’s completely inappropriate. Like, as I said, the chemist refused to sell it to me. Other doctors have said, You can use it on your face. You can use it on your eyelids. You can use it for as long as you want. Like it’s very mixed messages. And then, so you don’t know what you’re doing really. And that’s just like, [laugh] that’s quite frustrating. Because then you go to a new doctor and you’re like, Oh, yes, I’ve been doing this and this has been working, blah, blah, blah. And they’re like, Oh, well, you can’t do that. Like that’s awful. You have to stop doing that immediately. But there’s no other options. And you’re like, Oh, okay, well, what, what am I meant to do?

There was one cream that was amazing which they discontinued and I can’t remember what it was called. And then the steroids are just really hard to get hold of even if someone’s prescribed them to me before, they’re always like Are you sure you need them again? and it’s like well now you’ve given them to me and I’ve like adjusted my life and like routine with eczema to be with this cream I kind of do need it [laughs]. But they always do prescribe it eventually.

Most of the patients that I see have been under using corticosteroids. And they often get almost inappropriate steroid phobia, and they get that from other health professionals they sometimes get it from pharmacists, it can come at them from lots of different areas. And that comes from probably misinformation, a lot of the time. And, you know, not good knowledge on good use of how these products work and how they can be used safely. The NICE guidelines are very clear on this, they say the benefits of topical corticosteroids outweigh any risks. And that’s, that’s, you know, we know that, we have good studies to support that. We find that often people will be inappropriately cautious, and they’ll have very active eczema. You know, because they’re not using their corticosteroids effectively, or they’re not being advised or supported in the effective use of corticosteroid use. If you use a very potent corticosteroid for a very long time on skin that’s not inflamed, then you can run into side-effects. So I always think calling it steroid phobia’ is a bit unfair, because it’s, you know, it’s not like you shouldn’t be aware and mindful of possible side effects of treatments. But also you should be able to use them effectively. And if anything, we’re using slightly more potent corticosteroids in a slightly different way, to make sure that we can reduce inflammation. Particularly early on in the, you know, in a child with eczema, because we think that’s probably the most effective way to prevent them then getting, you know, more sustained and chronic eczema.

One thing I’ve come across recently is topical steroid withdrawal and addiction. When I’ve been using, when it got quite severe and I was referred back to my dermatologist, I was put on courses of prednisolone and Trimovate and I’ve had Protopic and Betnovate. Which are all, Protopic isn’t a steroid but they’re quite, the Betnovate and the Trimovate I think are quite potent. And I wanted to stay away from that because, as I mentioned earlier, I like naturally occurring products, something that’s not gonna have serious side effects on my skin. Which, what I’ve been reading up on is skin thinning, it becomes red and it can deteriorate. And it wasn’t really something I’d wanted to, I didn’t wanna go down that route because my skin is already quite red anyway. And I think it, it’s a bit harsh. But after talking with my dermatologist, who wasn’t too happy for me to go down the route without steroids I think. Because it has such a, it does have a really high success rate. I won’t, I won’t deny that. They’ve been using them for 50 years or so and they are really successful with people that have severe eczema. But after reading up on topical steroid addiction and withdrawal, some of the symptoms, such as regularly infected skin, it’s constantly swollen, red. There’s like a scent of iron actually that I noticed on my skin, which is quite odd. And reading up on some of these people who do suffer with it and are going through the withdrawal of it. It’s, it’s quite severe what they go through. Even though s-, steroids are such an easy route to go down. They, you just put it on for about three weeks or so and use it intermittently, and your eczema is gone. But these people are trying to sort of push the toxins and steroids out of their body, and have been for about two or three years. And they’re still going through symptoms of s-, swollen skin, it’s red, it’s cracked, it’s infected all the time. And I don’t think mine is as severe as theirs, possibly because mine is more stress related and my allergies aren’t as bad as theirs. But it is still a route I would like to explore. And I think I would really appreciate it if it was an option that doctors and dermatologists were more prepared to explore. Rather than accepting that the only route is sort of scientific research instead of going down the herbal route. And sort of just allowing a bit more preference from the patient, not necessarily what they’ve found to be successful in the past.