Topical corticosteroids have been used for about 50 years and their introduction was a milestone in dermatology. They are used to treat inflammatory skin conditions by suppressing the inflammatory reaction and relieving symptoms. However, they are not curative and attempts to increase potency have often been associated with more adverse effects. The emphasis should be on limited, selective, and careful use with clear explanation and instruction to patients.

Indications

• Eczema - the most important because it is very common both in adults and children (affecting 15-20% of schoolchildren and 2-10% of adults). Children are most at risk from misuse and adverse effects.¹ See separate article Atopic Dermatitis and Eczema.
• Contact dermatitis.²
• Seborrhoeic dermatitis (antifungals probably more appropriate).³
• Insect stings.
• Eczema associated with infection - with caution.
• Psoriasis - with caution.
• Other inflammatory skin conditions including: discoid lupus erythematosus; lichen planus under specialist supervision.

Evidence of efficacy

• Randomised controlled trials (RCTs) show treatment effect over placebo for atopic eczema.⁴
• There is consensus that topical steroids are effective for seborrhoeic dermatitis of the scalp in adults.³ There were however no RCTs comparing steroids.
• Short courses of steroids used episodically are effective by consensus, for treating seborrhoeic dermatitis of the face and body in adults.⁵
• In psoriasis, evidence of potent steroid efficacy similar to vitamin D derivatives is available but evidence of side-effects and flares of the disease on withdrawal were also found.^6,7,8,9

Pre-prescribing assessment and investigation

• Establish a correct diagnosis. Does the lesion fit the diagnostic criteria of, for example, atopic eczema?¹⁰
• Consider diagnoses which require a different treatment approach. For example: scabies, bacterial infection (suggested by crusting and weeping) herpes infection (suggested by vesicles or punched-out erosions).
• Consider wider management issues:
  • Aggravating factors.
  • Previous treatments.
  • Impact on quality of life.
  • Other medications.
  • Growth chart in children.¹

When should referral be considered?

Referral might be considered, occasionally before treatment if:

• Diagnosis is unclear.
• There are certain diagnoses where distribution and severity require referral
• Severe infection is suspected, e.g. eczema herpeticum.
• There is lack of response to treatment of the primary condition (see under 'Guidance', below)
• There is failure of treatment for secondary infection.
• There is contact dermatitis requiring patch testing.
• Additional advice or treatment is required,
• Use of immunomodulatory agents is to be considered (such as tacrolimus and pimecrolimus).¹¹
• Dietary factors are suspected.

Starting, monitoring and further guidance on use of topical steroids

Anecdotally and within articles written about use of topical steroids, there are a number of common criticisms, implied or overt, of general practitioners' prescribing of topical steroids.^12,13 This may reflect what is seen by specialists receiving referrals rather than what is going on more widely. Criticism includes:

• Prescribing inappropriate quantities. Usually, the quantities prescribed are too small.
• Prescribing an inappropriate strength of steroid and length of treatment. (The British National Formulary (BNF) classifies topical steroids as mild, moderate and potent).
• Prescribing emollients inadequately. These are not prescribed often enough, in sufficient quantity or with correct instructions.
• Prescribing generally with inadequate instructions in the use of both emollients and topical steroids.

Guidance has been issued with this in mind.¹⁰ There may be a place for use of printed information (Including detail of how to use emollients and topical steroids) and education involving practice nurses to help improve efficacy of treatments and information for patients. Examples can be obtained from the British Association of Dermatologists and the National Eczema Society.

Guidance can be summarised as follows:

• Choice of formulation is important:
  • Creams are best for weeping or moist areas.
  • Ointments are best for dry, scaly or lichenified areas.
  • Lotions are useful for larger or hair-bearing areas.
  • Occlusive dressings increase absorption. Caution and close supervision are required.
• Potency of steroid should be matched to age, disease severity and site. For example:
  • Face, genitals and flexures:
    • Skin is thin and self-occludes within the skin fold, thus increasing absorption.
    • Milder steroids should therefore be prescribed.
  • Eyelids:
    • Skin is thin. Restrict to an intermittent mild steroid for no more than 14 days and avoid eye contact.
    • Over the age of 35, beware risk of glaucoma if used for more than 14 days and monitor intraocular pressure (IOP).
  • Palms, soles of feet and scalp:
    • Skin is thicker. Stronger steroids are required.
    • Consider occlusive techniques.
  • Trunk and limbs in adults:
    • Use the weakest strength required to achieve control within 14 days, as judged by the severity of the inflammation and previous response to treatment.
  • Children:
    • Use weaker steroids, especially when a large area is to be treated.
    • Consider specialist referral if moderate-strength steroids are needed to maintain control.
• Duration of treatment:
  • Treatment gives only symptomatic relief and duration of treatment should be limited to a week for acute conditions.
  • In more chronic conditions, use for 4-6 weeks to achieve remission (for example, in chronic eczema).
  • Short bursts of stronger steroids can be used to gain control over a few days.¹⁴
• Quantity of steroid:
  • Give specific information on the quantity to be applied (as too much risks side-effects and too little may be ineffective). This can be specified according to the calculation that one fingertip unit (FTU, or length squeezed from tube between tip of finger and first skin crease) is enough to cover an area about twice the area of the palmar aspect of the hand (and weighs approximately 500 mg).
  • Application should be no more than twice daily and the National Institute for Health and Clinical Excellence (NICE) guidelines¹⁵ suggest that once daily may be as effective as more frequent applications. This may also reduce side-effects.
  • Specific guidance on how much cream or ointment should be prescribed is helpful. For example, a guide to quantities from the BNF for an acute eczema flare-up in adults is:

    Face and neck	30 g
    Both hands	30 g
    Scalp	30 g
    Both arms	60 g
    Both legs	100 g
    Trunk	100 g
    Groin and genitalia	30 g

• Use of emollients:
  • Topical steroids should not be used for emollient effect.
  • Emollients should be applied at least 30 minutes before the topical steroid.
  • Frequent and intensive emollient use in eczema will reduce the amount of steroid needed.
• Monitoring of treatment:
  • Regular review of treatment should be undertaken to ensure that minimum strength required is being used and to check for side-effects.
  • Care should be taken to follow up more closely use of stronger steroids, children, and in areas of the body where skin is thin.
  • Immunomodulatory agents such as tacrolimus and pimecrolimus are now available as an alternative to topical steroids. These are as effective but more expensive. Initiation usually requires referral.¹¹

Cautions/contra-indications

Topical corticosteroids are contra-indicated in:

• Untreated infection (bacterial, fungal and viral).
• Acne rosacea.
• Perioral dermatitis.
• Extensive plaque psoriasis.

Common side-effects

These may be systemic or local.^16,17,18

• Systemic side-effects:
  • These are more likely with more potent steroids, larger quantities, more frequent application and where absorption is greatest (certain sites of the body and occlusion enhance absorption).
  • Children, by virtue of skin type, surface area to weight ratio and disease severity are more at risk of systemic side-effects and should be monitored closely. The risk of growth restriction exists and growth should be monitored under specialist supervision where moderate strength steroids are required regularly.
  • Safe weekly limits to avoid systemic side-effects have been suggested:¹⁹

    Treatment period in months	Mild-to-moderate	Potent	Very potent
    Less than 2 months	100 g	50 g	30 g
    2-6 months	50 g	30 g	15 g
    6-12 months	25 g	15 g	7.5 g

• Localised adverse effects:
  These include:
  • Spreading infection.
  • Depigmentation.
  • Skin thinning.
  • Striae.
  • Telangiectasia.
  • Contact dermatitis.
  • Perioral dermatitis.
  • Acne.
  • Acne rosacea.
• Effects such as skin thinning are unlikely to occur in less than 4 weeks in mild-to-moderate strength steroids but can occur with potent steroids within 1-3 weeks. This will often, but not always, reverse within 4 weeks if stopped.
• If potent steroids are required for control of inflammation for more than 7 days in a 5-week period, referral is recommended because of the risk of local side-effects.
• Avoidance of infection may be promoted by steroid-antibiotic combinations (evidence is lacking), emollient antimicrobial preparations, not leaving tubs open, pump dispensers, and general hand hygiene measures.

Document references

1. Atopic eczema in children, NICE Clinical Guideline (December 2007)
2. Guidelines for the care of contact dermatitis, British Association of Dermatologists (2009)
3. Gupta AK, Bluhm R, Cooper EA, et al; Seborrheic dermatitis.; Dermatol Clin. 2003 Jul;21(3):401-12. [abstract]
4. Hoare C, Li Wan Po A, Williams H; Systematic review of treatments for atopic eczema.; Health Technol Assess. 2000;4(37):1-191. [abstract]
5. Topical steroids in seborrhoeic dermatitis, Clinical Evidence; [Subscription required]
6. Mason J, Mason AR, Cork MJ; Topical preparations for the treatment of psoriasis: a systematic review.; Br J Dermatol. 2002 Mar;146(3):351-64. [abstract]
7. Katz HI, Prawer SE, Medansky RS, et al; Intermittent corticosteroid maintenance treatment of psoriasis: a double-blind multicenter trial of augmented betamethasone dipropionate ointment in a pulse dose treatment regimen.; Dermatologica. 1991;183(4):269-74. [abstract]
8. Kragballe K, Barnes L, Hamberg KJ, et al; Calcipotriol cream with or without concurrent topical corticosteroid in psoriasis: tolerability and efficacy.; Br J Dermatol. 1998 Oct;139(4):649-54. [abstract]
9. British National Formulary
10. Guidelines for the management of atopic eczema, Primary Care Dermatology Society and British Association of Dermatologists (2006); Updated October 2009
11. Atopic dermatitis (eczema) - pimecrolimus and tacrolimus, NICE Technology Appraisal (2004)
12. Long CC, Funnell CM, Collard R, et al; What do members of the National Eczema Society really want?; Clin Exp Dermatol. 1993 Nov;18(6):516-22. [abstract]
13. Long CC, Finlay AY; Perceived underprescription of topical therapy.; Br J Gen Pract. 1993 Jul;43(372):305.
14. Charman C, Williams H; The use of corticosteroids and corticosteroid phobia in atopic dermatitis.; Clin Dermatol. 2003 May-Jun;21(3):193-200.
15. Atopic dermatitis (eczema) - topical steroids, NICE Technology Appraisal (2004)
16. Hengge UR, Ruzicka T, Schwartz RA, et al; Adverse effects of topical glucocorticosteroids.; J Am Acad Dermatol. 2006 Jan;54(1):1-15; quiz 16-8. [abstract]
17. Brazzini B, Pimpinelli N; New and established topical corticosteroids in dermatology: clinical pharmacology and therapeutic use.; Am J Clin Dermatol. 2002;3(1):47-58. [abstract]
18. Hoffmann K, Auer T, Stucker M, et al; Comparison of skin atrophy and vasoconstriction due to mometasone furoate, methylprednisolone and hydrocortisone.; J Eur Acad Dermatol Venereol. 1998 Mar;10(2):137-42. [abstract]
19. Coulson I, 1996 Topical Steroids for Skin Disease Dermatology In Practice March/April 5-8

Internet and further reading

• British Association of Dermatologists