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Topical corticosteroids

Reviewed by Dr Victoria Lewis, specialist registrar in dermatology

What are topical corticosteroids?

Corticosteroid medicines are derivatives of the natural corticosteroid hormones that are produced by the adrenal glands. These have many important functions in the body, including control of inflammatory responses. Corticosteroid medicines are mainly used for their effect in controlling inflammation, and topical corticosteroids are applied to the skin for the localised treatment of various inflammatory skin disorders.

Corticosteroids are often simply called steroids, but it should be noted that they are very different from another group of steroids, called anabolic steroids, which have gained notoriety because of their abuse by some athletes and body builders.

Topical corticosteroids for eczema include hydrocortisone, which is the same as the naturally-occurring corticosteroid cortisol, and synthetic corticosteroids such as betametasone, fluticasone and mometasone. They are applied to the skin in the form of creams, ointments and lotions and are the mainstay of controlling flare-ups of eczema.

Why are they used?

Topical corticosteroids are used to suppress the inflammation in the skin that causes flare-ups of eczema. They are not a cure as they have no effect on the underlying cause of the inflammation, but they do control the flare-up and relieve the symptoms, such as itching and redness. Controlling the itching reduces the desire to scratch and therefore reduces the chance of the eczema getting infected.

In cases where your eczema is infected you may be prescribed a topical corticosteroid that also contains an antibiotic or antiseptic.

How do they work?

Topical steroids are absorbed into the skin cells. They stop these cells from producing various inflammation-causing chemicals that are normally released when the skin reacts to allergens or irritation. These inflammation-causing chemicals include prostaglandins and various other inflammatory substances. They cause blood vessels to widen and other inflammatory substances to arrive, resulting in the affected area of skin becoming red, swollen and itchy. By preventing these inflammatory chemicals from being released in the skin, corticosteroids reduce inflammation and relieve its related symptoms such as itchiness.

Why are there different strengths of corticosteroids?

Topical steroids can be divided into four different strengths – mild, moderate, potent and very potent. When you first see your doctor about your eczema you will probably be prescribed a mild steroid, and if this doesn’t work a stronger one may subsequently be tried to control the inflammation. You may need different strengths of steroid for different areas of skin. As a general rule the lowest strength preparation that is effective should be used, as this minimises the risk of side effects. Very potent steroids should only be used for short periods of time, whereas milder ones can be used for longer.

The table below shows the potencies of some of the topical steroids that you may come across. Some contain additional ingredients such as antibiotics. NB. Corticosteroid preparations that also contain urea or salicylic acid are more potent than those containing the corticosteroid alone, as these ingredients increase the absorption of the steroid into the skin.

Brand name	Name of corticosteroid	Potency	Other active ingredients
.	.	.	.
Alphaderm cream	Hydrocortisone 1%	Moderate	Urea (humectant moisturiser)
Aureocort ointment	Triamcinolone acetonide 0.1%	Potent	Chlortetracycline (antibiotic)
Betacap scalp application	Betamethasone valerate 0.1%	Potent	.
Betnovate cream/ointment/lotion	Betamethasone valerate 0.1%	Potent	.
Betnovate-C cream/ointment	Betamethasone valerate 0.1%	Potent	Clioquinol (antiseptic)
Betnovate-N cream/ointment	Betamethasone valerate 0.1%	Potent	Neomycin (antibiotic)
Betnovate RD cream/ointment	Betamethasone valerate 0.025%	Moderate	.
Betnovate scalp application	Betamethasone valerate 0.1%	Potent	.
Bettamousse	Betamethasone valerate 0.12%	Potent	.
Calmurid HC cream	Hydrocortisone 1%	Moderate	Urea, lactic acid (humectant moisturisers)
Canesten HC cream	Hydrocortisone 1%	Mild	Clotrimazole (antifungal)
Clarelux foam	Clobetasol propionate 0.05%	Very potent	.
Cutivate cream/ointment	Fluticasone propionate	Potent	.
Daktacort cream/ointment	Hydrocortisone 1%	Mild	Miconazole (antifungal)
Dermacort cream	Hydrocortisone 0.1%	Mild	.
	Clobetasol propionate 0.05%	Very potent	.
	Clobetasol propionate 0.05%	Very potent	.
Dioderm cream	Hydrocortisone 0.1%	Mild	.
Diprosalic ointment	Betamethasone dipropionate 0.05%	Potent	Salicylic acid (keratolytic)
Diprosalic scalp application	Betamethasone dipropionate 0.05%	Potent	Salicylic acid (keratolytic)
Diprosone cream/ointment	Betamethasone dipropionate 0.05%	Potent	.
Diprosone lotion	Betamethasone dipropionate 0.05%	Potent	.
Econacort cream	Hydrocortisone 1%	Mild	Econazole (antifungal)
Efcortelan cream/ointment	Hydrocortisone 0.5%, 1%, 2.5%	Mild	.
Elocon cream/ointment	Mometasone furoate 0.1%	Potent	.
Elocon scalp lotion	Mometasone furoate 0.1%	Potent	.
Etrivex shampoo	Clobetasol propionate 0.05%	Very potent	.
Eumovate cream/ointment	Clobetasone butyrate 0.05%	Moderate	.
Eumovate eczema and dermatitis cream	Clobetasone butyrate 0.05%	Moderate	.
Eurax hydrocortisone cream	Hydrocortisone 0.25%	Mild	Crotamiton (anti-itch)
Fucibet cream	Betamethasone valerate 0.1%	Potent	Fusidic acid (antibiotic)
Fucidin H cream/ointment	Hydrocortisone acetate 1%	Mild	Fusidic acid (antibiotic)
Haelan cream/ointment/tape	Fludroxycortide	Moderate	.
Locoid cream/ointment/crelo/ lipocream/scalp lotion	Hydrocortisone 17-butyrate 0.1%	Potent	.
Locoid C cream/ointment	Hydrocortisone 17-butyrate 0.1%	Potent	Chlorquinaldol (antiseptic)
Lotriderm cream	Betamethasone dipropionate 0.064%	Potent	Clotrimazole (antifungal)
Metosyn cream/ointment	Fluocinonide 0.05%	Potent	.
Mildison lipocream	Hydrocortisone 1%	Mild	.
Modrasone cream/ointment	Alclometasone dipropionate 0.05%	Moderate	.
Nerisone cream/oily cream/ointment	Diflucortolone valerate 0.1%	Potent	.
Nerisone forte oily cream/ointment	Diflucortolone valerate 0.3%	Very potent	.
Nystaform HC cream/ointment	Hydrocortisone 0.5%, 1%	Mild	Nystatin, chlorhexidine (antifungal + antiseptic)
Synalar cream/ointment/gel	Fluocinolone acetonide 0.025%	Potent	.
Synalar 1 in 4 cream/ointment	Fluocinolone acetonide 0.00625%	Moderate	.
Synalar 1 in 10 cream/ointment	Fluocinolone acetonide 0.0025%	Mild	.
Synalar C cream/ointment	Fluocinolone acetonide 0.025%	Potent	Clioquinol (antiseptic)
Synalar N cream/ointment	Fluocinolone acetonide 0.025%	Potent	Neomycin (antibiotic)
Timodine cream	Hydrocortisone 0.5%	Mild	Dimeticone, nystatin, benzalkonium chloride (barrier +antifungal +antiseptic)
Tri-adcortyl cream/ointment	Triamcinolone acetonide 0.1%	Potent	Neomycin, gramicidin, nystatin (antibiotic + antifungal)
Trimovate cream	Clobetasone butyrate 0.05%	Moderate	Oxytetracycline, nystatin (antibiotic + antifungal)
Ultralanum plain cream/ointment	Fluocortolone	Moderate	.
Vioform-hydrocortisone cream/ointment	Hydrocortisone 1%	Mild	Clioquinol (antiseptic)

What are the possible side effects?

Many people are nervous about the prospect of using topical steroids because of fears about the possible side effects. These fears are generally unfounded because topical steroids are actually very safe when used correctly, and rarely cause side effects.

Some of the side effects that may be associated with topical steroids are described below. Local side effects affecting the skin are more likely than systemic side effects affecting the rest of the body, but are still rare if the steroid is used correctly.

The risk of experiencing side effects depends on the strength of the steroid used, the length of time it is used for, the area of skin treated, the size of the area of skin, and the nature of the skin problem. The chance of unwanted side effects is greatest when very potent steroids are used on large areas of skin for long periods of time. Unwanted side effects are very rare when a mild or moderately potent steroid is used for short periods to control flare-ups of eczema.

Local side effects

The most common side effects occur locally in the areas of skin treated with the steroid. Probably the most well known is thinning of the skin (atrophy), which sometimes results in permanent stretch marks (striae). Fine blood vessels may swell and become prominent under the skin surface (telangiectasia), again a permanent change There may be a temporary loss of pigment in the areas of skin treated; this may be more noticeable in dark-skinned people. Sometimes the skin may become allergic to the steroid, making the eczema appear to get worse. The skin may also bruise more easily and become more susceptible to infection. For this reason topical steroids should never be used to treat inflamed skin that is also infected, unless the infection is also being treated.

Systemic side effects

A systemic side effect is one that occurs within the body. If used on large areas of skin for prolonged periods of time, potent steroids can be absorbed into the bloodstream and affect other areas of the body. Extremely rarely this may cause side effects such as growth suppression or adrenal suppression. The adrenal glands produce the body’s natural steroid hormones. If sufficient topical steroid is absorbed into the body it can suppress this natural steroid production, which can lead to illness such as Cushing’s syndrome. Children who need frequent or prolonged courses of potent steroids are at a higher risk of systemic side effects than adults and should be referred to a dermatologist who may want to monitor their growth and development.

To minimise the risk of experiencing steroid side effects there are various precautions you can take.

Use the least potent steroid possible to control the inflammation.
Only apply the steroid to areas of skin affected by the skin disease.
Only use the steroid as often as prescribed by your doctor – no more than once or twice a day.
Apply the steroid sparingly – see below for how much to use.
Wherever possible, avoid using steroids for long periods of time and on large areas of skin.
Be aware that certain areas of skin – the face, genitals, raw skin, thin skin and areas of skin that rub together, such as beneath the breasts or between the buttocks - absorb more steroid than other areas.
Applying dressings over the area of skin treated with the steroid increases the absorption of steroid into the skin. You should only use dressings with your topical steroids if advised to by your doctor.
Once the inflammation is under control, reduce or stop using the steroid. Remember to keep using plenty of moisturisers to help prevent flare-ups.
Never use a topical steroid as a moisturiser.

Are they suitable for everyone?

Topical corticosteroids can be used safely by most people. However, they should not be applied to areas of skin that are affected by acne, including acne rosacea, as they will make these conditions worse. They should also not be used on infected areas of skin unless you are also receiving treatment for the infection.

What if I am pregnant or breastfeeding?

Topical corticosteroids should not generally be used during pregnancy unless considered essential by you and your doctor. Studies in animals have shown that corticosteroids applied to the skin of pregnant animals can cause abnormalities in the development of the foetus, such as cleft palate or retarded growth of the foetus in the womb. Studies in animals do not necessarily relate to effects in humans, but there may be a small risk of such effects if sufficient steroid is absorbed through the skin into the bloodstream of pregnant women. For this reason, you should not use topical steroids during pregnancy unless you have discussed it with your doctor. If you do use them, the chances of them being absorbed through the skin should be minimised by using the weakest strength possible, and not using them on large areas of skin, underneath airtight dressings, or for prolonged periods of time.

For the same reasons corticosteroids should not be used during breastfeeding unless considered essential by you and your doctor. Again, to minimise the possibility of steroids being absorbed through the skin and passing into the breast milk, you should not use them on large areas of skin, underneath airtight dressings or for prolonged periods of time. If you need to apply a topical steroid to the breasts it should be washed off carefully before breastfeeding to prevent the child ingesting it and then reapplied afterwards.

Are they suitable for children?

Children, especially babies, are more susceptible to the side effects of topical steroids, but this does not mean that they cannot be used safely. Again, the key is to use the weakest strength possible for as short a time as possible.. This should not cause side effects either locally or systemically.

More potent steroids should not be used in infants under one year of age and should be avoided or used for as short a time as possible to control flare-ups in older children.

Children with chronic severe eczema should have their growth monitored, as in these cases sufficient steroid may be absorbed to begin to affect the child’s normal growth.

Dressings are not suitable for applying to a child’s skin that has been treated with topical steroids as they will increase the absorption of the steroid into the body and increase the risk of side effects. Be aware that babies’ nappies will act as an occlusive dressing and so should not be used if you have applied a steroid to the baby’s bottom.

What else should I be aware of when using them?

Only mild steroids should be used on the face, and then only on the instruction of your doctor. The skin on the face is thinner and absorbs steroid more easily, making it more vulnerable to damage by the steroid.

Occlusive dressings are airtight dressings that are sometimes applied on top of the steroid to increase its absorption into problem areas of skin. However, as they increase absorption of the steroid they may also increase the chances of side effects and so should only be used on the advice of your doctor. In general they should only be used with milder steroids, and should not be used on children’s skin or the skin of the face.

Try not to apply moisturisers either directly before or after applying the steroid as this will dilute it and reduce its effects. Wait for 30-60 minutes between creams.

It is important that you avoid getting topical steroids into your eyes. Always wash your hands after application (unless you are treating eczema on your hands) to prevent accidentally getting the steroid in your eyes, and take care when applying steroids to the face.

Should I use cream or ointment?

As with moisturisers, the type of steroid formulation most suitable for you depends on the characteristics of your eczema and the area of skin affected. Lotions and gels are most suitable for hairy areas of skin. Creams are better for moist, weeping areas of skin, while ointments are most suitable for drier, scaly areas.

How much should I use?

The main thing to remember is to apply the steroid sparingly. The fingertip unit is often used as a simple way of measuring the correct quantities to apply to various parts of the body. This is explained in the ‘how to use your topical corticosteroid’ factsheet.

How long should they be used for?

This will depend on your individual circumstance, but as a general guide, acute flare-ups of eczema will normally be controlled by applying a steroid daily for a few days to a week. Chronic eczema may take up to four to six weeks of treatment before it is controlled.

Once the inflammation is controlled the steroid should be stopped if possible and moisturisers alone used. However, when treatment with the steroid is stopped there may be a tendency for the eczema to return, as the steroid does not treat the underlying cause. This is why it is important to avoid trigger factors, and to keep the skin hydrated with moisturisers to reduce the chance of further flare-ups. In addition, your doctor may suggest you use a steroid twice weekly on areas that have healed but are particularly prone to developing eczema.

Based on a text by Helen Marshall, pharmacist

Last updated 05.04.2007

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