What is the proper procedure for applying topical steroid with occlusion?

How to Apply Topical Steroid with Occlusion

The effectiveness of topical steroids can be significantly enhanced by applying them under occlusive dressings, which increases penetration and efficacy while potentially reducing the required potency of the steroid.

Proper Procedure for Occlusive Therapy

Step-by-Step Application Process:

1. Cleanse the affected area:

   • Wash with a gentle soap substitute or dispersible cream
   • Pat dry thoroughly (do not rub)
   • Avoid using regular soaps or detergents which can remove natural skin lipids 1

2. Apply the topical steroid:

   • Use the fingertip unit method: amount of medication from the fingertip to first crease of finger covers approximately 2% body surface area 2
   • Apply a thin layer to the affected area
   • Use the lowest potency steroid that effectively controls the condition 1

3. Apply the occlusive dressing:

   • Options include:
     • Plastic wrap/film (most common)
     • Plastic gloves (for hands)
     • Specialized occlusive dressings
   • Cover the treated area completely, ensuring edges are sealed

4. Duration of occlusion:

   • For most conditions: 6 out of 7 nights per week 1
   • Remove during daytime to allow skin to breathe
   • Total treatment duration depends on steroid potency:
     • Super-high potency: up to 3 weeks maximum
     • High/medium potency: up to 12 weeks maximum 2
     • Low potency: no specific time limit, but regular assessment needed

Important Considerations and Precautions

Potency Selection:

• Use the least potent steroid preparation required to control the condition 1
• Consider the treatment site - thinner skin areas (face, genitals) require lower potency steroids
• For resistant or lichenified eczema, higher potency may be needed initially

Monitoring for Side Effects:

• Watch for local adverse effects:

  • Skin atrophy
  • Striae
  • Telangiectasia
  • Folliculitis (common with potent topical steroids) 1

• Systemic absorption risks:

  • Occlusive dressings substantially increase percutaneous absorption 3
  • Monitor for HPA axis suppression with large areas of application
  • Consider periodic breaks in treatment to allow skin recovery

Special Considerations:

For Hands:

• Apply moisturizer followed by cotton or loose plastic gloves at night 1
• For daytime treatment, water-based moisturizers are safe under all gloves
• Oil-based moisturizers can break down latex and rubber gloves 1

For Children:

• Use lower potency steroids
• Shorter duration of treatment
• Avoid tight-fitting diapers or plastic pants in diaper area (acts as occlusive dressing) 3
• Monitor for growth suppression with prolonged use

Evidence of Effectiveness

Clobetasol propionate applied under occlusive plastic film on six out of seven nights for 6 months resulted in long-term hair regrowth in 18% of patients with severe alopecia areata, while no regrowth occurred on untreated sides 1. This demonstrates the enhanced efficacy provided by occlusion.

Common Pitfalls to Avoid

1. Overuse of high-potency steroids: Use the lowest effective potency, especially on thin skin areas
2. Prolonged continuous application: Implement periodic breaks to prevent adverse effects
3. Inadequate monitoring: Regularly assess for signs of skin atrophy or systemic absorption
4. Occlusion of infected areas: Never apply occlusive dressings over infected skin
5. Poor patient education: Ensure patients understand proper application technique and duration

Remember that occlusion significantly increases steroid absorption, which enhances efficacy but also increases the risk of side effects. Regular monitoring and appropriate steroid selection are essential for safe and effective treatment.