Hello and welcome again to this Skin Deep podcast where we look at skin-related issues, conditions and treatments in an interesting and informative way. I'm Dr Roger Henderson. I've been a doctor in the NHS for about 40 years and I've got a long-standing interest in this particular area of health. And I'm Dr George Moncrieff. I was a GP although I've now retired from my practice and I am a primary care advisor to the National Eczema Society.
And I am a former Chair of the Dermatology Council for England. Now, many of you listening to us today may be using topical steroids. Today, George and I are going to be talking about these, in particular, some of the problems that can be associated with their use. But I think right at the start of this podcast, George and I are really quite keen to say that we are both enormous fans of using topical steroids.
And I don't think either of us could have ever practised dermatology without using them. And I think that's probably right, isn't it, George? It would be impossible. They are amazing treatments for so many really unpleasant skin conditions. And the vast majority of people who use a topical steroid gain enormous benefit and experience no significant side effects. So we don't want to get across the impression for a moment that we are anti topical steroids.
They have a fundamental role, a cornerstone of the management of so much skin disease. And yeah, the idea of trying to practise medicine without them would be untenable. So yes, they do work for a lot of people when they're used correctly and sensibly. However, some people are concerned about topical steroids and I believe rightly so. And for some people, not only do they not work all that well, but they can actually cause quite dramatic and devastating inflammation in the skin.
And this is an area I believe really needs much more research and better understanding by the profession in particular. Largely because of the devastating consequences this can have for these individuals. Absolutely, and this is something that we're going to be exploring in much more detail with our special guest Briana Banos in the second of these episodes on topical steroid concerns. And so that's a thread that's going to be running through all this podcast with George and myself.
Um, but certainly my experience when I'm prescribing a topical steroid, one of the comments that sometimes a patient will say to me is, "oh, don't they thin the skin, Doctor?" And technically that is correct. Although for the vast majority of people, they don't use the steroids for long enough for that to be an impact. But we can't pretend it doesn't happen, can we? No we certainly can't. They do thin the skin and that is an important, really important, point.
Topical steroids are not intended to be used long-term. But that doesn't mean they don't end up being needed long-term. For example, if you've got moderate atopic eczema, the chances are you're going to have about 9 flares a year. And each time you have a flare, you may well need to use a topical steroid for, well, a minimum two weeks, probably four weeks, maybe longer. So you can see how you can end up using a topical steroid on and off for months and months on end.
And we do know that the skin starts to show signs of thinning and that can start after six weeks of steroid use and in some cases can happen in as little as two weeks. Particularly, if you put it on areas of skin that are already quite thin. So yes, they do thin the skin, and that is really concerning. And I think patients are right to bring that to attention and right to be alert to that possibility. They do get absorbed a bit and we'll come on to that.
In the deeper layers of the skin, you have a very important protein called collagen. And one of the functions of collagen is to provide support for the skin. If you haven't got that support, the skin can stretch, you get stretch marks. And blood vessels aren't as well supported. So if you knock those, they can bruise under the skin. The steroids have many other effects on the skin, weakening what we call the skin barrier.
The skin barrier is this important outer part of our body that prevents water escaping. Without it, we would die in a few hours from dehydration. And it prevents bad things like bacteria and allergens getting through the skin and causing problems. But there are a lot of really quite sophisticated things going on in that barrier which steroids mess up. For example, they raise the pH, rendering the skin alkaline. Normally, the surface of the skin is slightly acidic.
And that's not by chance, it's by design. And if you raise the pH, rendering it alkaline, you alter the activity of a number of things going on in the skin. Which make the skin barrier even more vulnerable and weaker. And of course, all these issues to do with the barrier are more worrying in the areas of the body where you've got very thin skin. Where the barrier already is vulnerable. But that's where you get eczema, and that's where you therefore need to put the steroids.
Older people, and even more importantly in infants, the skin is particularly thin. And so, if it's starting off thin and vulnerable, putting a steroid on there is potentially more worrying. So that is a real cause for concern. And I think when people say that to us, they're absolutely right. That's why we need to be using them responsibly and ideally for just short bursts for a couple of weeks when we can. Agreed.
And one of the beauties that we like as doctors is that they are very easily absorbed. They're quite small molecules you get in the topical steroids, so the skin soaks them up very fast. But again, we can run into a bit of a double whammy, if we're not too careful here. If you've got skin that's got a little bit thinner from using them and the skin is absorbing them quite fast, it can start to absorb more steroid than perhaps we might want that patient to be using.
Yeah, and get down into that deeper layer of the skin or occasionally get absorbed into the body. And we do know that, for example, in infants who have a very large surface area compared to their bodyweight when compared to adults, that ratio is not in their favour. If you treat large areas of skin in an infant, the amount of steroid that they absorb can have an effect on their body's ability to make normal steroids. And that can be worrying, or it can have more side effects generally.
The other thing to bear in mind is that if you're putting a steroid onto thin skin areas, like around the eye, and that's where you get eczema, and that's where you often need to use a steroid. Up to 30% of that steroid gets through the skin and into the body. I've even heard doctors say steroids aren't absorbed. They're wrong. They are absorbed. And of course, these thin skin areas are even more, as I was just saying earlier, a bigger issue for the very young and the very old.
Um, so it is something we need to think about, particularly with the more potent topical steroids. And as you say, it is a vicious cycle. The steroid is thinning the skin, causing more absorption, which causes more thinning. So, it is something to be aware of. Going back to what I said right at the beginning though, the vast majority of people who use a topical steroid do not run into these problems. But it can happen, and it's something we need to think about.
Absolutely, and I think, again, in previous podcasts, you and I have often talked about the importance of language when you're trying to explain either skin conditions or treatments to patients. And I think topical steroids is a really good example of this, because some people looking at their steroid pack today may see things like 'use very sparingly' or 'avoid broken skin'. What does 'sparingly' mean?
And is it a tiny dab behind the ear once a week or is it lathered over you in one go in one day? So, we can run the risk of topical steroids being underused and then almost being between a rock and a hard place where no one gets better and no one is very happy. And that's a really frustrating scenario, isn't it? One tip I'd share with you, is if you're going to see a doctor about your skin, why don't you put all your treatments in a large carrier bag? All the treatments you're using.
The things you're using to wash yourself with, your hair with, the emollients you're using, and most importantly, the treatments that you've been prescribed or buying over-the-counter. And take with you, for example, the topical steroid treatments. Because I've seen patients who have been prescribed a topical steroid, 6 months ago, and they bring it with them and it's barely been touched.
And they're saying, "why isn't my condition getting better?" I look at them and say, "have you been using the treatment?" "Yes, I've been using it sparingly." When we talk about topical steroids, we describe how much we expect people to use, and we use the fingertip unit. You squeeze it out and the distance from the end of the crease on the index finger to the tip of the finger is half a gram. And that should be enough to cover 2 palms.
So, if you're using it the way I'd expect you to use it, you'd have got through that tube in 2 and a half weeks. And here we are 6 months later, it hasn't gone. So yeah, the words like 'avoid broken skin', well, eczema is broken skin and that's where you've got to put it on. And 'sparingly' just doesn't mean anything. So it is really frustrating when people are given well-intentioned, but misguided advice to underuse their topical steroids.
And I don't want our advice today to fall into that trap. They are superb treatments, but they've got to be used responsibly. Absolutely. And if anyone listening is thinking, I'm not quite sure if I'm using my topical steroid correctly or how I should be using it. What I would say, the real message from the wayside pulpit here today is just go and ask your pharmacist, ask your doctor, ask your practice nurse. There is no such thing as a stupid question, ever.
So, do please get your mind clear as to how you should be using your topical steroid. And one other thing when you were just talking there, George, that sort of sprang into my head, patients will not only talk about thinning of skin. Increasingly over the last decade, I found the awareness of allergy being much greater than it ever used to be. And I've also heard healthcare professionals say to patients, "you can't be allergic to topical steroids." That couldn't be more wrong, could it?
It couldn't be more wrong, no. Allergy to the topical steroid molecule is well-documented, it was first described in the last century. And I think it's much more common than we as a profession recognise. In fact, studies from Europe and the USA have shown the incidence from patch test clinic patients ranges from just 0.5% to over 10%, 10.7%. So there's certainly a measurable number of patients who are allergic. So it does exist.
Creams have a high-water content and so need preservatives, which is one of the reasons why I prefer generally to prescribe ointments. They have no water and so don't need preservatives. And allergies to the preservatives that are used and other ingredients in creams are even more common than allergy to topical steroids. So you can imagine a real nightmare scenario there.
You've got an allergic condition caused by your topical steroid, which a topical steroid should make better, but it's just adding fuel to that fire. And so, you've got a real problem trying to sort that all out. It is an issue and we shouldn't dismiss it and we need to take that seriously. But we also mustn't forget that topical steroids themselves can affect our immune system. They're powerful immune-suppressing agents. Our immune system is really a marker of how well we can remain.
And I think that can also be a plus and a minus in their use. Yes, topical steroids are pretty powerful broad immune-suppressing agents, and that's how they work. When the immune system is misbehaving, as it does in eczema, you can calm that down and the eczema gets better usually. But when you're depending on that immune system to keep an infection at bay, as for example a fungal infection, putting a steroid on that just drives the fungus down deeper.
It drives it down into the deeper layers of the skin. And because it's now no longer on the surface, it doesn't look scaly. It's more difficult to diagnose and it's a lot more difficult to treat. Putting a steroid on when there's some infections can be an absolute disaster. And then finally, there are a number of skin conditions that I have never seen in somebody who doesn't use topical steroids. A classic example is perioral dermatitis, a not uncommon condition usually in young women.
When they get spots or an eczematous rash around the mouth, strangely, steroids initially seem to make that a bit better, but then make it much worse. So they use a stronger steroid, which makes it a bit better. But then it gets even worse and you're into this vicious cycle and the only way of managing that in the long run is to keep steroids completely away from the face. It also makes rosacea worse.
So there are some skin conditions, which we don't understand entirely why, but they are caused and driven by topical steroids. That's a nice place to come full circle to. And also just to remind everyone listening to what we said right at the top of this podcast. That it's quite unusual, the vast majority of people using topical steroids, um, have no problems with them whatsoever.
They do what they say on the tin, they are safe, they are effective, and much of what we've talked about today doesn't actually happen. But it is worthwhile, now in this day and age, to just mention the possibilities that people may have, especially if they're using topical steroids in the longer-term. And I do hope that you found what George and I have said today interesting and helpful.
And as always, if you do have any questions about your use of topical steroids, do discuss them with your doctor or healthcare professional. So I endorse everything that Roger's just said there. I couldn't practice dermatology without using topical steroids. They are really wonder drugs, but they have these problems. And there's a further problem they cause, which we're going to talk about in another podcast, called Topical Steroid Withdrawal Syndrome, which is ghastly.
So we're going to devote a whole podcast to that. So we do hope you'll join us next time. We'd also like to thank our sponsor, AproDerm®, for their help in putting these Skin Deep podcasts together. We couldn't have done it without them. And finally, if you do enjoy these podcasts, and I know many of you are and that's fantastic to hear, do rate and review us because it really does help us in putting them together. And send us some feedback we really do love to hear from you.
Until the next time we speak it's goodbye from George. Goodbye. And it's goodbye from me. Goodbye