Diflucortolone Valerate – Salicylic Acid
Topical Corticosteroid – Keratolytic
Action And Clinical Pharmacology: Nerisalic combines the anti-inflammatory, antipruritic and vasoconstrictive activity of diflucortolone valerate and the keratolytic effects of salicylic acid.
Both diflucortolone valerate and its split ester are topically active.
Indications And Clinical Uses: The topical treatment of chronic eczema, psoriasis vulgaris, neuro-dermatitis and scaly crusty dermatoses which respond to corticosteroid therapy.
Nerisalic is not suitable for the treatment of perioral dermatitis and rosacea.
Contra-Indications: In patients who have shown hypersensitivity, allergy or intolerance to diflucortolone valerate or other corticosteroids or salicylic acid or to any excipients in the preparation. Nerisalic should not be applied to skin areas with fissures, erosions, scratches or excoriations.
Topical steroids are contraindicated in untreated bacterial and/or fungal skin infections. Topical steroids should not be applied in cases of tuberculosis of the skin, or syphilitic skin infections, chickenpox, eruptions following vaccinations and viral diseases of the skin in general.
Manufacturers’ Warnings In Clinical States: Nerisalic is not for ophthalmic use and, consequently, should not be used in or near the eyes.
Nerisalic should not be applied in rhagades and ulcerations (e.g. lower leg ulcers). Inclusion of salicylic acid in this preparation increases steroid penetration into the viable epidermis thereby increasing the potential for skin atrophy.
Pregnancy: The safety of Nerisalic during pregnancy has not been established. Teratogenic and embryotoxic effects of diflucortolone valerate have been reported following dermal application in animal studies. Nerisalic should be used during pregnancy only if the potential benefits justify the potential risks to the fetus.
Lactation: Systemically administered corticosteroids can appear in human milk and can suppress growth, interfere with endogenous corticosteroid production or cause adverse effects. Caution should be exercised when Nerisalic is administered to a nursing woman since it is not known whether the ingredients of Nerisalic are excreted in human milk.
Precautions: Systemic absorption of topical corticosteroids has produced reversible hypothalamic-pituitary-adrenal (HPA) axis suppression, manifestations of Cushing’s syndrome, hyperglycemia and glucosuria in some patients.
Significant systemic absorption may occur when steroids are applied over large areas of the body or if used under an occlusive dressing. To minimize this possibility when long-term therapy is anticipated, interrupt treatment periodically or treat one area of the body at a time. It is recommended that patients receiving a large dose of a potent topical steroid applied over a large surface area be evaluated periodically for evidence of HPA axis suppression by using the urinary free cortisol and ACTH stimulation tests. If HPA axis inhibition is observed, an attempt should be made to withdraw the drug, to reduce the frequency of application or substitute a less potent steroid. Recovery of HPA axis function is generally prompt and complete upon discontinuation of the drug. Infrequently, signs and symptoms of steroid withdrawal may occur, requiring supplemental systemic corticosteroids.
If irritation or hypersensitivity reactions develop, Nerisalic should be discontinued and appropriate therapy initiated.
Prolonged use of topical corticosteroid products may produce atrophy of the skin and of s.c. tissues, particularly on flexor surfaces and on the face, telangiectasias, hirsutism and steroid induced acne. If this is noted, discontinue use of the product. Long-term therapy with Nerisalic should be avoided.
In cases of bacterial or fungal skin infections, appropriate antibacterial agents should be used as primary therapy. If it is considered necessary, Nerisalic may be used as an adjunct to control inflammation, erythema and itching.
Nerisalic should be used with caution in patients with stasis dermatitis and other skin diseases associated with impaired circulation, on extremities of diabetics with impaired circulation or on patients with inherent compromised cardiovascular circulatory problems.
Patients should be advised to inform subsequent physicians of the prior use of corticosteroids.
Systemic absorption of the corticosteroid and salicylic acid may be increased with elevated body temperature or occlusive dressings. Patients with elevated temperatures should be monitored for HPA axis effects and occlusive dressings should not be used.
Occlusive dressings should not be applied if there is an elevation of body temperature.
Because of the risk of salicylate intoxication, long term or large area and occlusive use of Nerisalic should be avoided in patients with impaired renal function.
Since salicylic acid is absorbed almost completely, the simultaneous topical or internal use of other preparations containing salicylic acid or salicylate is inadvisable. The concentration of salicylic acid contained in the preparation is not high enough for the treatment of secondary skin diseases caused by bacteria or fungi. Additional antibacterial or antimycotic therapy is recommended in these cases.
Children: Due to their larger skin surface area to body weight ratio, children may demonstrate a greater susceptibility to the topical corticosteroid-induced HPA axis suppression and Cushing’s syndrome than mature patients.
Suppression of the HPA axis, Cushing’s syndrome and intracranial hypertension have been reported in children receiving topical corticosteroids. Manifestations of adrenal suppression in children include linear growth retardation, delayed weight gain, low plasma cortisol levels and absence of response to ACTH stimulation. Manifestations of intracranial hypertension include bulging fontanelles, headaches and bilateral papilledema.
Administration of topical corticosteroid to children should be limited to the least amount compatible with an effective therapeutic regimen. Chronic corticosteroid therapy may interfere with the growth and development of the children.
The following tests may be helpful in evaluating HPA axis suppression due to corticosteroid component: urinary free cortisol test and ACTH stimulation test.
Because of the risk, of salicylate intoxication, long term or large area and occlusive use of Nerisalic should be avoided in babies, infants and in children.
Adverse Reactions: The following local adverse reactions are reported when topical corticosteroids are used as recommended. These reactions are listed in an approximate decreasing order of occurrence: burning, itching, irritation, dryness folliculitis, hypertrichosis, acneiform eruptions, hypopigmentation, perioral dermatitis, allergic contact dermatitis, maceration of the skin, secondary infection, skin atrophy, telangiectasia, striae and miliaria. Hypothalamic-pituitary-adrenal axis suppression have also been reported following topical corticosteroid therapy.
Posterior sub-capsular cataracts have been reported following systemic use of corticosteroids.
In addition, the salicylic acid contained in the preparation may produce some desquamation, local reddening of the skin, pruritus, burning, pain and stinging. Hypersensitivity to salicylic acid may occur. If this occurs, discontinue use
Symptoms And Treatment Of Overdose: No specific antidote is available. Treatment should be symptomatic.Symptoms: Percutaneous absorption of corticosteroids can occur when large amounts of corticosteroids are applied. Toxic effects may include ecchymosis of skin, peptic ulceration, hypertension, aggravation of infection, hirsutism, acne, edema and muscle weakness due to protein depletion.
High levels of salicylates may cause temporary hearing or visual disturbance, drowsiness and nausea.
Treatment: Appropriate symptomatic treatment of corticosteroid and/or salicylic acid overdosage is indicated. Acute hypercorticoid symptoms are usually reversible. Treat electrolyte imbalance, if necessary. In cases of chronic toxicity, slow withdrawal of corticosteroid is advised.
Dosage And Administration: Nerisalic should be applied as a thin film to diseased areas 2 to 3 times daily in the first week of treatment. During subsequent weeks, 1 or 2 applications/day are sufficient. The duration of the treatment should not exceed a total of 4 weeks.
The total dose applied weekly should not exceed 100 g.
If improvement is not noted within a few days to a week, the local application of Nerisalic should be discontinued and the patient re-evaluated.
Availability And Storage: Each g of oily cream contains: diflucortolone-21-valerate 0.1% and salicylic acid 3% in a water-in-oil emulsion. Nonmedicinal ingredients: hydrocarbons (white petrolatum, paraffin), white wax and dehymuls E. There is no preservative. Tubes of 30 g. Store at 15 to 30°C. Avoid freezing.
NERISALIC® Stiefel Diflucortolone Valerate – Salicylic Acid Topical Corticosteroid – Keratolytic