Differences in Cutaneous Irritation of Five Commonly Used Topical Products
July 2016 | Volume 15 | Issue 7 | Original Article | 870 | Copyright © July 2016
Zoe Diana Draelos MD
Dermatology Consulting Services, High Point, NC
INTRODUCTION: Irritation, such as burning and stinging, on the site of application, is a common side effect of topical dermatologic products including creams, lotions, sprays, and foams. This effect may be more pronounced when applying products to atopic or psoriatic skin. The composition of the vehicle may affect the extent of the irritation. This study compared the irritation and erythema potential of 7 different topical dermatologic products to determine the products with the least likelihood of causing discomfort when applied.
METHODS: Seven sites on the anterior leg of 30 subjects were dry shaven with 10 upward strokes. Subjects rated the stinging of petrolatum (negative control), isopropyl alcohol (positive control), Cetaphil Lotion, triamcinolone 0.1% cream, triamcinolone 0.2% spray, betamethasone foam, and clobetasol 0.05% spray, 1 minute after product application, using a scale of 0 (no symptoms) to 10 (intolerable stinging/burning). The investigator assessed erythema at the sites 30 minutes after application of the products using a scale of 0 (none) to 4 (severe).
RESULTS: Stinging rating score of each product was statistically significant from one another. Petrolatum produced the least stinging (0) and isopropyl alcohol the most (10). Stinging with triamcinolone spray, Cetaphil Lotion, and triamcinolone cream ranked in the lower half of the rating scale (all below 5). Betamethasone foam and clobetal spray ranked the highest at >7. When corrected for the erythema caused by shaving, triamcinolone spray and Cetaphil Lotion produced the least amount of erythema of all the products tested.
DISCUSSION: Rapid evaporation of the volatile vehicle of triamcinolone spray and the non-irriating nature of the medication left behind may contribute to its low erythema and stinging. This product may be an appropriate choice for patients with compromised skin but who require the advantages and conveniences of a spray vehicle. J Drugs Dermatol.
The skin is the largest organ in the body and has an abundant supply of blood vessels and nerve fibers. It conveys information on the sense of touch. Nerve fibers gather information from a variety of sensory receptors on the skin surface (mechanoceptors, thermoreceptors, and nocicpetors) that detect changes in pressure, temperature, and pain, respectively. The size shape, number, and distribution of receptors vary depending on the location of the skin, which, in turn, affect skin sensitivity. Fingertips and lips tend to be most sensitive while soles of the feet are less so due to the density of sensory receptors.
Pain is an unpleasant sensory and emotional feeling and is the most common experience reported by patients.1 Nociceptors detect pain and quickly pass this sensory information to the central nervous system. Feeling of pain sensation is subjective; therefore, the same stimulus can be experienced differently in different circumstances by different people.1 Some pain serves as a warning against tissue damage or an indication of already inflicted damage, eg, touching a hot stove. Other pain simply hurts without an obvious protective purpose, eg, skin irritation in response to topical products.
Skin irritation, namely burning and stinging, on the site of application is a common side effect of topical dermatologic medications whether in cream, lotion, foam, or spray form. The effect may be more pronounced when applying products to atopic or psoriatic skin or when using products that contain alcohol. Recognizing which products possess a lower potential for irritation and erythema may be beneficial for patients undergoing treatment for dermatoses-related conditions.
Triamcinolone spray is a mid-potency topical corticosteroid with a reported cooling sensation2; yet, it contains dehydrated alcohol that evaporates on contact. Other commonly prescribed topical corticosteroids in spray or foam vehicle contain different ingredients and different types of alcohol, such as cetyl alcohol, ethanol, and steryl alcohol. A frequent perception of these spray and foam formulations is that they are associated with stinging and burning upon application; therefore, are underutilized even though they may be beneficial to the patient with dermatoses. To determine the validity of this perception, the present study compared the irritation and erythema potential of 4 different topical corticosteroids available for the relief of inflammatory and pruritic manifestations