PL Detail-Document

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PL Detail-Document

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.
Drug
Adult
Dosage Form and Sizesb
AWP ($) for Selected
Dosea
Products
Commentsc,e
(Brand is listed if generic is
unavailable)
Very High Potencyd
Augmented*
betamethasone
dipropionate
(Diprolene)
Generics available
Clobetasol propionate
(Clobex, Olux, Olux-E,
Temovate, Temovate E)
Generics available
Continued…
QD to BID
0.05% Lotion (30, 60 mL)
0.05% Oint (15, 45, 50 gm)
0.05% Gel (15, 50 gm)
30 mL lotion 57.23
60 mL lotion 112.77
15 gm oint 30
45 gm oint 127.71
50 gm oint 73
QD
(Shampoo)
0.05% Cream
(15, 30, 45, 60 gm)
15 gm cream (emollient)
27.50
BID
0.05% Cream (emollient base)
(15, 30, 60 gm)
30 gm cream (emollient)
42.35
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)
60 gm cream (emollient) 69
0.05% Shampoo (118 mL)
0.05% Spray (60, 125 mL)
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…
More. . .
Copyright © 2012 by Therapeutic Research Center
P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com ~ www.pharmacytechniciansletter.com
(PL Detail-Document #280908: Page 2 of 12)
Drug
Adult
Dosea
Commentsc,e
Products
unavailable)
Very High Potency, continued
Clobetasol propionate,
continued
•
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.
50 mL scalp application
39.60
•
118 mL shampoo 385.29
60 mL spray (Clobex)
332.56
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.
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
125 mL spray (Clobex)
598.25
Diflorasone diacetate
QD to TID
0.05% Oint (15, 30, 60 gm)
QD to BID
0.1% Cream (30, 60, 120 gm)
30 gm cream 220.43
60 gm cream 379.80
120 gm cream 721.62
QD to BID
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
Generic available
Fluocinonide
(Vanos)
Halobetasol propionate
(Ultravate)
Generics available
60 mL lotion 288.96
120 mL lotion 528.56
50 gm foam 169.86
100 gm foam 313.14
15 gm oint 37.56
30 gm oint 51.86
60 gm oint 100.16
More. . .
Drug
Adult
Dosea
Commentsc,e
Products
unavailable)
High Potencyd
Amcinonide
Generics available
BID to TID
0.1% Cream (15, 30, 60 gm)
0.1% Lotion (60 mL)
0.1% Oint (60 gm)
Augmented*
betamethasone
dipropionate (Diprolene
AF) Generics available
Betamethasone
dipropionate
BID
0.05% Cream (15, 50 gm)
QD to BID
0.05% Oint (15, 45 gm)
15 gm oint 50.45
45 gm oint 87.01
Desoximetasone
BID
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
BID
0.05% Cream (15, 30, 60 gm)
15 gm cream 70.51
30 gm cream 141.03
60 gm cream 282.07
BID to
QID
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
(Topicort)
Generics available
Diflorasone diacetate
Generics available
Fluocinonide
Generics available
Continued…
15 gm cream 26
30 gm cream 38.88
60 gm cream 66.50
60 mL lotion 162.86
60 gm oint 194.40
15 gm cream 36.43
50 gm cream 81.65
•
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
absorption.1
More. . .
Drug
Adult
Dosea
Commentsc,e
Products
unavailable)
High Potency, continued
Fluocinonide, continued
Halcinonide
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
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
15 gm oint 10.10
BID to TID
0.1% Cream (30, 60, 216 gm)
0.1% Oint (30, 60 gm)
0.5% Oint (15 gm)
Generics available
BID to
QID
Medium Potencyd
Betamethasone
dipropionate
QD to BID
(cream)
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
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
(Halog)
Triamcinolone acetonide
Generics available
Betamethasone valerate
(Luxiq)
Generics available
BID
(lotion)
QD to TID
BID
(Luxiq)
60 mL lotion 72
•
Medium or low potency
agents are preferable when a
large body surface area needs
to be treated.1
•
Medium potency agents are
generally well tolerated when
used for three months or less
on nonfacial,
nonintertriginous areas.1
Continued…
More. . .
Drug
Adult
Dosea
Commentsc,e
Products
unavailable)
•
Medium Potency, continued
TID
Clocortolone pivalate
0.1% Cream
(30, 45, 75, 90 gm)
(Cloderm)
Desoximetasone
BID
0.05% Cream (15, 60, 100 gm)
TID to QID
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
BID to
QID
0.05% Cream (15, 30, 60 gm)
15 gm cream 19.90
30 gm cream 27.50
60 gm cream 44.73
BID to TID
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 BID
4 mcg/cm2 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
(Topicort LP)
Generics available
Fluocinolone acetonide
Generics available
Fluocinonide (emulsified
base)
Generics available
Flurandrenolide
30 gm cream 141.66
45 gm cream 212.48
75 gm cream 354.14
90 gm cream 424.97
15 gm cream 62.43
60 gm cream 231.49
100 gm cream 195.09
(Cordran, Cordran SP)
Occlusive dressings should be
avoided with betamethasone
dipropionate and fluticasone
propionate 0.05% cream per
FDA-approved labeling.
More. . .
Drug
Adult
Dosea
Products
Commentsc,e
unavailable)
Fluticasone propionate
QD to BID
(Cutivate)
Generics available
0.05% Cream (15, 30, 60 gm)
15 gm cream 22.18
30 gm cream 34.18
60 gm cream 53.88
15 gm oint 22.25
30 gm oint 34.30
60 gm oint 54.10
BID
0.005% Oint (15, 30, 60 gm)
QD
0.05% Lotion (60, 120 mL)
60 mL (Cutivate) 126.72
120 mL (Cutivate) 779.70
Hydrocortisone butyrate
BID to TID
(Locoid,
Locoid Lipocream)
Generics available
BID
(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)
Hydrocortisone valerate
BID to TID
15 gm cream 19.69
45 gm cream 42.25
15 gm cream
(Locoid Lipocream) 85.76
45 gm cream
60 gm cream
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
(Westcort)
Generics available
0.2% Cream (15, 45, 60 gm)
0.2% Oint (15, 45, 60 gm)
More. . .
Drug
Adult
Dosea
Products
Commentsc,e
unavailable)
QD
Mometasone furoate
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
BID
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
BID to
QID
0.025% Cream
(15, 80, 454 gm)
0.025% Lotion (60 mL)
0.025% Oint (15, 80, 454 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
(Elocon)
Generics available
Prednicarbate
(Dermatop)
Generics available
Triamcinolone acetonide
(Kenalog)
Generics available
TID to QID
(Spray)
BID to TID
(0.1%
lotion)
Continued…
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)
100 gm spray (Kenalog)
310.92
More. . .
Drug
Adult
Dosea
Commentsc,e
Products
unavailable)
Triamcinolone acetonide,
BID to
continued
QID
Low Potencyd
Alclometasone
dipropionate
BID to TID
0.5% Cream (15 gm)
15 gm cream 11.10
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
(Aclovate)
Generics available
Desonide
(Desonate, DesOwen,
Verdeso)
Generics available
BID to TID
BID
(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
•
Hydrocortisone is available
by prescription and OTC.
The 2.5% strength is
prescription. Some 1%
formulations are prescription
while others are OTC.
•
Consider low potency agents
for children, pregnant
women, the elderly, and
patients with large areas to be
treated.1
•
Low potency agents are
absorption.1
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
More. . .
Drug
Adult
Dosea
Products
Commentsc,e
unavailable)
Low Potency, continued
Fluocinolone acetonide
(Capex, DermaSmoothe/FS)
Generics available
QD
(Shampoo)
TID to QID
(Cream,
Solution)
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
TID (Oil)
Hydrocortisone
up to QID
OTC
Generics available
Hydrocortisone
0.5% Cream (28, 56 gm)
0.5% Oint (38.3 gm)
56 gm cream 4.49 (retail
price)
(AWP not available)
up to QID
(Cortaid, Cortizone-10)
Generics available
Some products OTC
1% Cream (28, 56, 454 gm)
1% Oint (28, 454 gm)
price)
price)
454 gm cream 40 (retail
price)
(AWP not available)
Hydrocortisone, continued
Generics available
BID to
QID
2.5% Cream
(20, 28, 30, 454 gm)
(AWP not available)
2.5% Oint (20, 28.3, 454 gm)
2.5% Lotion (60, 120 mL)
More. . .
Drug
Adult
Dosea
Products
Commentsc,e
unavailable)
Low Potency, continued
Hydrocortisone acetate
U-cort
Some available OTC
Generics available
BID to
QID
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 BID 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; BID = twice daily, TID = three time daily; QID = 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]);
More. . .
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.
More. . .
Project Leader in preparation of this PL DetailDocument: Melanie Cupp, Pharm.D., BCPS
5.
References
6.
1.
2.
3.
4.
Drake LA, Dinehart SM, Farmer ER, et al.
Guidelines of care for the use of topical
glucocorticoids. J Am Acad Dermatol 1996;35:6159.
National Psoriasis Foundation.
Topical steroids
potency
chart.
http://www.psoriasis.org/Page.aspx?pid=469.
(Accessed August 11, 2012).
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.
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).
7.
8.
Fougera.
Knowledge center:
steroid potency
comparison.
http://www.fougera.com/knowledge_center/steroidpot
ency.asp. (Accessed August 12, 2012).
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. 10th ed.
Philadelphia, PA: Lippincott Williams & Wilkins;
2012. p. 925-43.
Haber RM. Topical management of recalcitrant
psoriasis and eczema.
Skin Therapy Lett FP
2010;6(3):1-4.
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.
Letter/Prescriber’s Letter. September 2012.
Pharmacist’s
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,
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