Dr Phil Hammond, broadcaster and sessional GP in Bristol

Patients and GPs need to fight their steroid phobia

Do you use FTUs? Do you tell your patients to use them? Do you even know what an FTU is? I had some vague recollection of the fingertip unit as a measure of topical dermatology treatments, particularly steroids, but until last weekend, I thought it meant that you covered your fingertip in ointment before applying it thinly to the affected area. Now that I’ve been to a dermatology symposium, I can confidently assert that an FTU is the amount of ointment or cream covering the distance from the tip of your index finger to the first joint as the preparation is squeezed out of the tube. One FTU is sufficient to cover a body area of two hands (roughly one buttock depending how big yours are).

I even have a handy map of how many hands the rest of the body comprises, depending on the person’s age. For example, the entire leg and foot of a 2-year old child is two FTUs, the FTUs in question being those of the adult applying the steroid, not the toddler’s fingertips. There isn’t an easy way of remembering how many FTUs correspond to what part of the body without looking it up, which is why, I guess, so few of us mention FTUs to patients in our 2-minute chats. And we’re not alone—the symposium largely comprised consultant dermatologists and only one in five slavishly explained FTUs to patients.

So why does this matter? Dr Sandeep Cliff, Consultant Dermatologist at Surrey and Sussex Healthcare NHS Trust, spoke passionately of the need to address steroid phobia among patients. This reluctance to use topical treatments in particular means that many patients end up on far more potent systemic treatment, such as methotrexate or ciclosporin, when their symptoms could have been controlled if they’d used enough steroid ointment.

Dr Cliff provided evidence that mild and moderate steroids rarely cause systemic side-effects and the ‘thin shiny skin’ that patients (and doctors) fear was often normal, healthy skin recovering from thickening and inflammation. More potent steroids were absorbed into the bloodstream but this was only transient and—if the same logic is applied as in asthma, stepping up to put out the fire of inflammation and stepping down once it had gone out—side-effects were rarely a problem. When they did occur, it was more likely that they came from inhaled steroids (many people with eczema also have asthma) rather than via the skin, which is a far better barrier to absorption than the lungs.

All of this made perfect sense, but there are still plenty of doctors and pharmacists who are so cautious in the use of steroids that the bulk of a dermatologist’s clinic may just be adjusting existing treatment to the correct dose. Dr Cliff quoted surveys showing that patients, GPs, and yes, even consultants, get very confused about how strong the two dozen or so different creams are, and that there needs to be clear labelling on the tube, not just on the box, so that everybody can tell at a glance.

The use of dermatology nurses in follow up and support of patients has apparently led to dramatic improvements in effective treatment for psoriasis and eczema. However, dermatology is a non-sexy specialty and will never attract the funding for enough nurses. So it’s up to all of us to learn and teach our FTUs and encourage patients to bring all their tubes to the surgery so that we can check they’re using enough. But above all, we need to get over our own steroid phobia. Dr Cliff told a great story about taking a course of oral prednisolone for gout, but stopping after a day because he was convinced he’d put on weight. Fear, it seems, spreads faster than steroids.

Dr Phil’s third book Sex, sleep or scrabble? Seriously funny answers to life’s quirkiest questions is out in October.