Fluticasone Propionate Cream

Overview

Mechanism of Action

• Anti-inflammatory - suppresses phospholipase A2, reducing arachidonic acid release and blocking synthesis of prostaglandins and leukotrienes
• Antiproliferative - slows keratinocyte turnover (useful in psoriasis)
• Immunosuppressive - reduces cytokine production (IL-1, IL-2, TNF-α)
• Vasoconstrictive - reduces erythema and edema

FDA-Approved Indications (Topical)

Dosing

• Children ≥3 months and adults: Apply a thin film to affected areas once daily to twice daily; once symptoms are controlled, step down to a less potent agent
• Safety and efficacy have not been evaluated beyond 4 weeks of continuous use

• Children ≥3 months and adults: Apply thin film once daily; not evaluated beyond 4 weeks

• Adults only: Apply thin film twice daily

Important: Fluticasone propionate and fluticasone furoate are NOT interchangeable - they have different potencies and dosing regimens. - The Harriet Lane Handbook, 23rd ed., p. 1495

Potency Classification

• Lippincott Illustrated Reviews: Pharmacology, p. 1511

Adverse Effects

Local (most common)

• Skin atrophy and striae (especially with prolonged use or occlusion)
• Irritation, burning, pruritus
• Folliculitis and acneiform eruptions
• Hypopigmentation
• Perioral dermatitis
• Hypertrichosis
• Allergic contact dermatitis
• Secondary infections (bacterial, fungal)
• Miliaria

Ocular

• Cataracts and glaucoma have been reported - avoid contact with eyes

Systemic (rare, with extensive/prolonged use)

• Hypothalamic-pituitary-adrenal (HPA) axis suppression - especially in young children with large surface area application
• Growth retardation in children with excessive use
• Cushing-like features
• The Harriet Lane Handbook, 23rd ed., p. 1537

Contraindications & Precautions

• Avoid on the face, axillae, or groin (higher absorption, skin thinning risk)
• Do not use under occlusive dressings unless directed - increases systemic absorption
• Reassess diagnosis if no improvement within 2 weeks
• Pregnancy: Use with caution; systemic absorption is low but topical corticosteroids can cause fetal harm in animal studies
• CYP3A4 inhibitors (e.g., ritonavir, ketoconazole): Can increase systemic fluticasone levels, increasing risk of HPA suppression and Cushing syndrome
• Do not use for perioral dermatitis or rosacea (can worsen both)

Practical Tips

• Apply only to affected areas - not as a general moisturiser
• Use the smallest effective amount for the shortest duration
• Avoid wrapping or covering treated areas with bandages
• Once inflammation is controlled, taper to a lower-potency agent or switch to a non-steroidal maintenance therapy (e.g., tacrolimus or pimecrolimus for atopic dermatitis)
• Intermittent ("weekend") dosing of fluticasone propionate cream has evidence for reducing relapse risk in atopic dermatitis - Dermatology 2-Volume Set 5e

Available Formulations Summary

Piles (Haemorrhoids)

Definition

Anatomy

• Internal haemorrhoids - originate above the dentate line, covered by columnar or transitional mucosa (insensate - so usually painless)
• External haemorrhoids - located below the dentate line, covered by squamous epithelium (pain-sensitive)
• Sleisenger and Fordtran's GI and Liver Disease

Pathophysiology

• Man's upright posture - increases hydrostatic pressure in the venous plexus
• Absence of valves in the portal venous system
• Raised intra-abdominal pressure - from straining during defecation, pregnancy, chronic cough, or ascites
• Shearing forces during defecation lead to mucosal trauma (bleeding) and caudal displacement of the anal cushions (prolapse)
• This causes impaired venous drainage, progressive engorgement, local stasis, and transudation of fluid (causing pruritus)
• With time, fragmentation of supporting connective tissue (normal with ageing, but accelerated in haemorrhoidal disease) leads to loss of elasticity - cushions no longer retract after defecation
• Increased levels of circulating matrix metalloproteinases are associated with symptoms, suggesting connective tissue degradation plays a key role
• Bailey and Love's Short Practice of Surgery, 28th ed.

Classification

Internal Haemorrhoids (Grades I-IV)

External Haemorrhoids

• Sleisenger and Fordtran's GI and Liver Disease; Bailey and Love's Short Practice of Surgery, 28th ed.

Clinical Features

Key point: Pain = think of another diagnosis. Uncomplicated internal haemorrhoids bleed but do not hurt. - Bailey and Love's Short Practice of Surgery, 28th ed.

Thrombosed External Haemorrhoid

• Sudden onset, olive-shaped, painful, blue subcutaneous swelling at the anal margin
• Follows straining, coughing, or heavy lifting
• Usually in a lateral position at the anal margin
• Natural history: may resolve, suppurate, fibrose into a skin tag, or spontaneously rupture with clot extrusion

Risk Factors

• Chronic constipation / straining
• Low-fibre diet
• Prolonged time sitting on the toilet
• Pregnancy
• Portal hypertension / liver cirrhosis
• Increasing age (connective tissue fragmentation)
• Chronic diarrhoea (loose stools also increase risk)

Diagnosis

1. History - nature of bleeding, prolapse, pain
2. Inspection - perianal skin, anal verge; ask patient to strain
3. Digital rectal examination - internal haemorrhoids are generally not palpable
4. Proctoscopy / Anoscopy (key investigation) - visualises internal haemorrhoids and grades protrusion
5. Sigmoidoscopy/Colonoscopy - essential to exclude colorectal malignancy as a cause of rectal bleeding, especially in patients >40 years or with alarm features

"Haemorrhoids located elsewhere than the classic 3, 7, 11 o'clock positions should raise concern for other diseases - carcinoma, lymphoma, condyloma." - Sleisenger and Fordtran's GI and Liver Disease

Management

Step 1 - Conservative (All Grades)

• High-fibre diet (20-30 g/day) and adequate fluid intake (6-8 glasses/day)
• Stool softeners (e.g., docusate sodium) if stools remain hard
• Polyethylene glycol 3350 for constipation
• Avoid prolonged sitting on the toilet; avoid straining
• Warm sitz baths for comfort
• Topical agents: Phenylephrine/mineral oil/petrolatum or mild glucocorticoid creams temporarily relieve pain/itching (note: steroid creams predispose to local infections)
• Phlebotonics (flavonoids such as diosmin/hesperidin, plant extracts, calcium dobesilate): improve venous tone, stabilise capillary permeability, reduce bleeding; superior to placebo; excellent safety profile - particularly useful for Grade II-III

Step 2 - Office-Based Procedures (Grade I-III)

Step 3 - Surgical (Grade III-IV, Failed Office Procedures)

• Grade III and IV haemorrhoids
• Grade II not cured by non-operative treatment
• Mixed haemorrhoids with well-defined external component
• Bleeding causing anaemia
• Thrombosed external haemorrhoid presenting within 48 hours (clot evacuation under local anaesthesia)

• Bailey and Love's Short Practice of Surgery, 28th ed.; Sleisenger and Fordtran's GI and Liver Disease

Management by Grade - Summary

Complications of Haemorrhoids

• Chronic blood loss anaemia (uncommon)
• Strangulation (irreducible Grade IV with sphincter spasm)
• Thrombosis
• Ulceration and infection
• Pruritus ani (from mucus discharge)

Complications of Surgery

• Post-operative bleeding (primary, reactionary, secondary)
• Urinary retention
• Anal stenosis (if skin bridges not preserved)
• Faecal incontinence (rare, from sphincter damage)
• Anal fissure
• Pelvic sepsis (rare but potentially life-threatening, especially after RBL)

Special Situations

• Pregnancy: Conservative management preferred; RBL and haemorrhoidectomy generally deferred until post-partum
• Portal hypertension/Cirrhosis: Treat conservatively; haemorrhoidectomy carries high risk of bleeding; caution with all interventions
• Immunocompromised/Diabetics: Bowel preparation recommended before RBL; higher infection risk
• Anticoagulated patients: Increased bleeding risk; manage conservatively where possible

Treatment of Piles (Haemorrhoids)

Step 1 - Conservative (Medical) Management

Dietary & Lifestyle Measures

• High-fibre diet: 20-30 g/day - softens stools, reduces straining
• Fluid intake: 6-8 glasses of non-alcoholic, non-caffeinated beverages daily
• Avoid prolonged sitting on the toilet - reduces sustained venous engorgement
• Avoid straining - most important modifiable factor
• Sitz baths: Warm water soaks for 10-15 min after bowel movements - reduce discomfort and spasm

Laxatives & Stool Softeners

Topical Agents

• Local anaesthetic/astringent creams (e.g. phenylephrine + mineral oil + petrolatum, lidocaine-based preparations) - temporarily relieve pain and pruritus
• Witch hazel preparations - mild astringent, topical soothing
• Glucocorticoid-based creams (e.g. hydrocortisone) - reduce inflammation and itch; caution: predispose to local infection (e.g. candidiasis) and should not be used long-term
• Glycerin suppositories have little role in treating haemorrhoids

Phlebotonics (Venotonics)

• Diosmin/Hesperidin (Daflon), Rutoside, Calcium dobesilate
• Mechanism: improve venous tone, stabilise capillary permeability, reduce oedema, increase lymphatic drainage
• Superior to placebo for acute symptoms; reduce bleeding; excellent safety profile
• Particularly useful for Grade II-III, and in pregnancy
• Available as oral tablets or suppositories

"Phlebotonics are superior to placebo in treating acute hemorrhoid symptoms and have an excellent safety profile." - Sleisenger and Fordtran's GI and Liver Disease

Step 2 - Office-Based (Non-Excisional) Procedures

1. Rubber Band Ligation (RBL)

• Grades: Primarily Grade II and III; can be used for Grade I if large enough
• Technique: A tight elastic band is placed just proximal to the dentate line (above it - critical to avoid pain) using a slotted anoscope (Barron's bander) or suction device (CRH-O'Regan, ConMed SpaceBander)
• Mechanism: Band causes ischaemic necrosis → tissue sloughs within 7-10 days → fibrosis anchors the remaining cushion
• One to three haemorrhoids can be banded; typically 1 per session to minimise pain; reassess in 4-6 weeks; most patients need ≤3 procedures
• Contraindication: Do NOT place band at or distal to the dentate line - causes severe pain from somatic innervation; band must be removed immediately if too distal
• Not used for external haemorrhoids

2. Injection Sclerotherapy

• Grades: I and II (small, bleeding haemorrhoids)
• Agent: 5% phenol in arachis oil (or almond oil); 3-5 mL per haemorrhoid injected submucosally at the apex of the pedicle (not into the haemorrhoid itself)
• Mechanism: Causes fibrosis that obliterates vascular channels and provides a scar to support prolapsing mucosa
• Technique: Injected above the dentate line through anoscope; pain during injection = needle in wrong position (withdraw immediately); rapid mucosal bulging turning white = too superficial (risk of ulceration)
• Repeated every 8 weeks if needed
• Advantage: Can be used in anticoagulated patients (unlike RBL)
• Complications: Superficial ulceration, rare pelvic sepsis/prostatitis (if too deep), anaphylaxis (rare), impotence (reported)
• Largely superseded by RBL due to higher complication risk and technically more demanding - Bailey and Love's, 28th ed.; Pfenninger & Fowler's Procedures for Primary Care

3. Infrared Photocoagulation (IRC)

• Grades: Grade I (best), Grade II
• Mechanism: Infrared radiation applied for 1.5 seconds to 2-3 sites proximal to the haemorrhoidal plexus; coagulates tissue → fibrosis
• Multiple sites treated per visit
• Results comparable to RBL for Grade I; less effective for larger haemorrhoids
• Best suited for Grade I, especially in patients who have experienced pain with RBL
• Complications rare (pain, bleeding uncommon) - Current Surgical Therapy, 14th ed.; Sleisenger and Fordtran's GI and Liver Disease

4. Cryotherapy

• Uses liquid nitrogen to freeze and destroy haemorrhoidal tissue
• Largely fallen out of favour - difficult to control depth of destruction, prolonged procedure, foul-smelling discharge from necrosis - Sleisenger and Fordtran's GI and Liver Disease

5. Doppler-Guided Haemorrhoidal Artery Ligation (HAL / HALO)

• Grades: II and III
• A Doppler probe identifies and ligates the feeding arteries to the haemorrhoidal columns transanally; can be combined with mucopexy (suture plication of prolapsed mucosa)
• Less painful than conventional haemorrhoidectomy; no excision
• HubBLe trial: HAL has significantly lower recurrence rates than RBL, but is more expensive and time-consuming
• Growing evidence supports it as an effective, minimally invasive alternative - Bailey and Love's, 28th ed.; Current Surgical Therapy, 14th ed.

Step 3 - Surgical Treatment

• Grade III haemorrhoids unresponsive to office-based procedures
• Grade IV haemorrhoids (most)
• Symptomatic external haemorrhoids unresponsive to conservative treatment
• Mixed internal + external haemorrhoids with well-defined external component
• Bleeding causing anaemia
• Thrombosed external haemorrhoid presenting within 48 hours (clot evacuation)
• Patient preference after failed office procedures

1. Ferguson Hemorrhoidectomy (Closed) - USA Standard

• Most common haemorrhoid operation in the United States
• V-shaped incision in perianal skin → haemorrhoid elevated off sphincters → vascular pedicle suture-ligated (2-0 Vicryl) → mucosal defect closed with running suture (last few mm left open to drain)
• Can use scalpel, cautery, or energy devices (LigaSure/Harmonic - faster, but higher cost; must carefully identify internal sphincter)
• Position: Prone jack-knife under spinal anaesthesia (preferred)
• Long-term recurrence: ~26% at median 17 years; 11% require additional procedure - Current Surgical Therapy, 14th ed.

2. Milligan-Morgan Hemorrhoidectomy (Open) - UK/European Standard

• Most common operation in the UK and Europe
• Identical to Ferguson except wounds are left open to heal by secondary intention
• Anoderm between haemorrhoids injected with dilute adrenaline (1:300,000) to reduce bleeding
• Artery forceps applied → V-shaped cut → dissection reveals internal sphincter → transfixion ligature at pedicle apex → haemorrhoid excised → skin bridges preserved (critical to prevent anal stenosis)
• Wound healing is slower than closed technique; outcomes are otherwise similar

3. Stapled Haemorrhoidopexy (PPH - Procedure for Prolapse and Haemorrhoids)

• Grades: I-III circumferential internal haemorrhoids without a bulky external component
• Technique: Circular EEA stapler removes a circumferential band of mucosa and submucosa 3-4 cm proximal to the dentate line → no external wounds → staple line above dentate line (less pain) → repositions prolapsed cushions, disrupts vascular pedicle
• Does NOT excise haemorrhoids - flattens and repositions them; may flatten minor external disease but does not adequately treat large external haemorrhoids
• Purse-string suture placement (circumferential submucosal, ~2 cm proximal to haemorrhoidal pedicle) is the key technical step; must check vagina digitally in women before firing to avoid rectovaginal fistula
• Advantages: Less post-operative pain, faster recovery, better short-term quality of life
• Disadvantages: Higher long-term recurrence than conventional haemorrhoidectomy; external haemorrhoids may persist
• Serious complications (rare): Staple line dehiscence, pelvic sepsis, rectovaginal fistula, tenesmus from staples near dentate line, rectal perforation, staple line stricture - Current Surgical Therapy, 14th ed.; Pfenninger & Fowler's Procedures for Primary Care; Bailey and Love's, 28th ed.

Treatment of External Haemorrhoids

Thrombosed External Haemorrhoid (Perianal Haematoma)

Treatment by Grade - Summary

Special Situations

2024 ASCRS Guidelines - Key Recommendations

• Strong recommendation: Disease-specific history and physical examination for all patients
• Conditional recommendation: Complete colonoscopic evaluation in patients with symptomatic haemorrhoids AND rectal bleeding (to exclude colorectal malignancy)
• Strong recommendation: Office-based procedures for most Grade I-II and selected Grade III haemorrhoids refractory to conservative treatment; haemorrhoid banding is the most effective office procedure
• Selected patients with thrombosed external haemorrhoids: early surgical excision may be beneficial
• Grade III-IV or external haemorrhoids: typically offered excisional haemorrhoidectomy
• The AGA (2026) additionally endorses both banding and infrared coagulation as safe, effective options before surgery for Grade I-III