Overview
Topical corticosteroids are used for the treatment of inflammatory conditions of the skin (other than those arising from an infection), in particular eczema, contact dermatitis, insect stings, and eczema of scabies. They are generally used to relieve symptoms and suppress signs of the disorder when other measures such as emollients are ineffective. Corticosteroids suppress the inflammatory reaction during use; they are not curative and on discontinuation a withdrawal reaction (rebound or flare) may occur. Withdrawal reactions are thought to occur after long-term continuous or inappropriate use of topical corticosteroids (particularly those of moderate to high potency). Signs and symptoms are reported to happen within days to weeks of stopping long-term topical corticosteroid treatment. A flare of the underlying skin disorder is the most common withdrawal reaction. Rarely, a specific type of withdrawal reaction may occur in which skin redness extends beyond the initial area of treatment, with burning or stinging that is worse than the original condition. For further information on topical corticosteroid withdrawal reactions, see Important safety information in the individual drug monograph).
Topical corticosteroids are not recommended in the routine treatment of urticaria; treatment should only be initiated and supervised by a specialist. They should not be used indiscriminately in pruritus (where they will only benefit if inflammation is causing the itch) and are not recommended for acne vulgaris.
Systemic or very potent topical corticosteroids should be avoided or given only under specialist supervision in psoriasis because, although they may suppress the psoriasis in the short term, relapse or vigorous rebound occurs on withdrawal (sometimes precipitating severe pustular psoriasis). See the role of topical corticosteroids in the treatment of psoriasis.
In general, the most potent topical corticosteroids should be reserved for recalcitrant dermatoses such as chronic discoid lupus erythematosus, lichen simplex chronicus, hypertrophic lichen planus, and palmoplantar pustulosis. Potent corticosteroids should generally be avoided on the face and skin flexures, but specialists occasionally prescribe them for use on these areas in certain circumstances.
When topical treatment has failed, intralesional corticosteroid injections may be used. These are more effective than the very potent topical corticosteroid preparations and should be reserved for severe cases where there are localised lesions such as keloid scars, hypertrophic lichen planus, or localised alopecia areata.
Perioral lesions
Hydrocortisone cream 1% can be used for up to 7 days to treat uninfected inflammatory lesions on the lips. Hydrocortisone with miconazole cream or ointment is useful where infection by susceptible organisms and inflammation co-exist, particularly for initial treatment (up to 7 days) e.g. in angular cheilitis. Organisms susceptible to miconazole include Candida spp. and many Gram-positive bacteria including streptococci and staphylococci.
Choice of formulation
Water-miscible corticosteroid creams are suitable for moist or weeping lesions whereas ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required. Lotions may be useful when minimal application to a large or hair-bearing area is required or for the treatment of exudative lesions. Occlusive polythene or hydrocolloid dressings increase absorption, but also increase the risk of side effects; they are therefore used only under supervision on a short-term basis for areas of very thick skin (such as the palms and soles). The inclusion of urea or salicylic acid also increases the penetration of the corticosteroid.
In the BNF publications topical corticosteroids for the skin are categorised as ‘mild’, ‘moderately potent’, ‘potent’ or ‘very potent’; the least potent preparation which is effective should be chosen but dilution should be avoided whenever possible.
Absorption through the skin
Mild and moderately potent topical corticosteroids are associated with few side-effects but care is required in the use of potent and very potent corticosteroids. Absorption through the skin can rarely cause adrenal suppression and even Cushing’s syndrome, depending on the area of the body being treated and the duration of treatment. Absorption is greatest where the skin is thin or raw, and from intertriginous areas; it is increased by occlusion.
For further information on side-effects that may occur from absorption through the skin, see Corticosteroids, general use.
Suitable quantities of corticosteroid preparations to be prescribed for specific areas of the body
| Area of body | Creams and Ointments |
|---|---|
| Face and neck | 15 to 30 g |
| Both hands | 15 to 30 g |
| Scalp | 15 to 30 g |
| Both arms | 30 to 60 g |
| Both legs | 100 g |
| Trunk | 100 g |
| Groins and genitalia | 15 to 30 g |
| These amounts are usually suitable for an adult for a single daily application for 2 weeks | |
Compound preparations
The advantages of including other substances (such as antibacterials or antifungals) with corticosteroids in topical preparations are uncertain, but such combinations may have a place where inflammatory skin conditions are associated with bacterial or fungal infection, such as infected eczema. In these cases the antimicrobial drug should be chosen according to the sensitivity of the infecting organism and used regularly for a short period (typically twice daily for 1 week). Longer use increases the likelihood of resistance and of sensitisation.
The keratolytic effect of salicylic acid facilitates the absorption of topical corticosteroids; however, excessive and prolonged use of topical preparations containing salicylic acid may cause salicylism.
Topical corticosteroid preparation potencies
Potency of a topical corticosteroid preparation is a result of the formulation as well as the corticosteroid. Therefore, proprietary names are shown.
Mild
- Hydrocortisone 0.1–2.5%
- Dioderm
- Mildison
- Synalar 1 in 10 dilution
Mild with antimicrobials
- Canesten HC
- Daktacort
- Econacort
- Fucidin H
- Hydrocortisone with chlorhexidine hydrochloride and nystatin
- Terra-Cortril
- Timodine
Moderate
- Betnovate-RD
- Eumovate
- Haelan
- Modrasone
- Synalar 1 in 4 Dilution
- Ultralanum Plain
Moderate with antimicrobials
- Trimovate
Moderate with urea
- Alphaderm
Potent
- Beclometasone dipropionate 0.025%
- Betamethasone valerate 0.1%
- Betacap
- Betesil
- Bettamousse
- Betnovate
- Cutivate
- Diprosone
- Elocon
- Hydrocortisone butyrate
- Locoid
- Locoid Crelo
- Metosyn
- Mometasone furoate 0.1%
- Synalar
Potent with antimicrobials
- Aureocort
- Betamethasone and clioquinol
- Betamethasone and neomycin
- Fucibet
- Lotriderm
Potent with salicylic acid
- Diprosalic
Very potent
- Clarelux
- Dermovate
- Etrivex
Very potent with antimicrobials
- Clobetasol with neomycin and nystatin
Use in children
Children, especially infants, are particularly susceptible to side-effects. However, concern about the safety of topical corticosteroids in children should not result in the child being undertreated. The aim is to control the condition as well as possible; inadequate treatment will perpetuate the condition. A mild corticosteroid such as hydrocortisone 0.5% or 1% is useful for treating nappy rash and hydrocortisone 1% for atopic eczema in childhood. A moderately potent or potent corticosteroid may be appropriate for severe atopic eczema on the limbs, for 1–2 weeks only, switching to a less potent preparation as the condition improves. In an acute flare-up of atopic eczema, it may be appropriate to use more potent formulations of topical corticosteroids for a short period to regain control of the condition. A very potent corticosteroid should be initiated under the supervision of a specialist. Carers of young children should be advised that treatment should not necessarily be reserved to ‘treat only the worst areas’ and they may need to be advised that patient information leaflets may contain inappropriate advice for the patient’s condition.
- Hydrocortisone
- Hydrocortisone with miconazole
- Salicylic acid
Related treatment summaries
- Corticosteroids, general use
