Resident Editor: Juliana Macri, M.D..
Faculty Editor: Ryan Arakaki, M.D.
Background
- Class refers to the strength of topical steroids and is determined by both potency and vehicle.
- The steroid class selected depends on the affected body part and the condition being treated (lower classes on the face or intertriginous areas; higher classes on the extremities, hands, or feet)
- Indications for topical steroids include conditions with hyperproliferation, inflammation, and immunologic involvement. Topical steroids also relieve burning and pruritic symptoms
- Use on a fungal infection will exacerbate the condition, so perform a skin scraping with KOH before prescribing. Avoid anti-fungal – steroid combination
Steroid vehicles and application:
- Ointments:
- Petroleum-based, greasy (patients often dislike)
- Better for hydration, occlusion, and absorption
- Useful for dry, thick, hyperkeratotic lesions
- Avoid hairy and intertriginous areas (can cause skin maceration and folliculitis)
- Creams:
- Water suspended in oil
- More cosmetically acceptable but less potent than ointments
- Drying effect
- Often contain preservatives (which can irritate and cause an allergic reaction)
- Lotions:
- Minimally greasy and occlusive
- Contain alcohol (drying effect good for oozing lesions, may cause stinging/burning)
- Useful for hairy and intertriginous areas given good penetration with minimal residue
- Gels:
- Alcohol-based with a jelly-like consistency
- Dries quickly
- Useful for hairy or oily areas (like scalp) or wet lesions (bullae)
- Application tips
- Hydration and occlusion promote steroid penetration
- Applying after bathing improves the effectiveness
- Occlusion with plastic wrap can increase penetration several-fold (good for extremities). Recommend using overnight, but not on the face or intertriginous areas, and shortening duration of use
Side Effects From Topical Steroids
- Atrophic changes (increased risk with higher potency, occlusion, thin skin, and age)
- Easy bruising, increased fragility, striae, ulceration
- Can be mitigated by concurrent topical tretinoin (Retin-A) 0.1% if chronic use required (though difficult to adhere to, not commonly used)
- Infections (especially if inappropriate treatment of fungal or bacterial infection)
- Aggravation of cutaneous infection, masked infection (tinea incognito), secondary infections
- Re-evaluate diagnosis if the rash worsens or does not improve with steroids
- Miscellaneous
- Contact dermatitis (often due to additives, rarely can have an allergy to the steroid agent itself)
- Steroid-induced acne, rosacea
- Delayed wound healing
- Hypertrichosis (hirsutism)
- Hypopigmentation
- Systemic effects
- High-dose steroids may have enough absorption to cause systemic effects (e.g. hypertension, hyperglycemia, glaucoma) and HPA axis suppression, especially when used on a broken skin barrier.
Prescribing Considerations
- Consider generic availability and patient’s formulary to increase adherence. Counsel patient to reach out for alternative if cost-prohibitive.
- Must consider potency, frequency, and duration of therapy
- Potency
- Low potency steroids preferred for long-term use, large surface areas, on the face, intertriginous areas, and other areas with thinner skin
- High potency steroid can be used in severe disease, areas with thicker skin (e.g. palms, soles). Never use on face, intertriginous areas. Caution with occlusion.
- Frequency
- Once or twice daily for most preparations. Titrate to a minimum frequency that still provides relief
- Duration
- Be aware of side effects, tolerance, and tachyphylaxis with prolonged use
- Do not use ultra-high potency for >3 weeks at a time. Use intermittent schedule with tapering and one-week steroid-free interval, as needed
- Low-high potency steroids should be limited to <3 months. Shorter if with occlusion or on thin skin.
- Anticipate the amount required for appropriate treatment and prescribe accordingly (see Table 8).
Table 7: Classes of Topical Steroids
Note: common preparations in bold
Class |
Potency |
Indication |
Generic |
Brand |
1 |
Ultra High |
Severe, unresponsive inflammatory dermatoses Do not use >3 weeks; never use on face or groin |
Clobetasol propionate 0.05% Betamethasone dipropionate 0.05% Fluocinonide 0.1% |
Clobex, Temovate® Diprolene® Vanos
|
2 |
Very High |
Severe inflammatory dermatoses (e.g., severe atopic or contact dermatitis, psoriasis) |
Desoximetasone 0.25%, 0.05% Fluocinonide 0.05% |
Topicort® Lidex® |
3 |
Medium to High |
Moderate dermatoses |
Triamcinolone acetonide 0.5% Fluticasone propionate 0.005% Amcinonide 0.1% |
Cinalog® Cutivate® Cyclocort® |
4, 5 |
Medium |
Moderate dermatoses |
Betamethasone valerate 0.1%, 0.12% Desoximetasone 0.05% Flucoinolone acetnoide 0.025% Fluticasone propionate 0.05% Hydrocortisone butyrate 0.1% Hydrocortisone valerate 0.2% Mometasone furoate 0.1% Triamcinolone acetonide 0.05%, 0.1% |
Beta-Val® 0.1%, Luxiq® 0.12% Topicort LP® Synalar® Cutivate® Locoid® Westcort® Elocon® Triderm® |
6 |
Low |
Mild dermatoses |
Desonide 0.05% Fluocinolone 0.01% Hydrocortisone butyrate 0.1% |
Desonate®
Locoid® |
7 |
Least potent |
Very mild, self-limiting dermatoses |
Hydrocortisone 1%, 2.5% |
|
Fingertip Unit
1 FTU = 0.5g = Amount that can be squeezed from the fingertip to the first crease of the finger
Enough to cover 2 hands (one side) worth of skin
Face and neck = 2.5 FTU
Trunk (front or back) = 7 FTU
Arm = 3 FTU
Leg = 6 FTU
Foot = 2 FTU
Table 8: Required Steroid Amount/Week
Body Area |
Quantity (grams) |
Face and neck |
15-30 |
Scalp |
15-30 |
Both hands |
15-30 |
Groin and genitalia |
15-30 |
Both arms |
30-60 |
Both legs |
100 |
Trunk |
100 |
References
Miller, JA, Munro DD. Topical corticosteroids: clinical pharmacology and therapeutic use. Drugs 1980;19:119.
Ference JD, Last AR. Choosing Topical Corticosteroids. Am Fam Physician. 2009;79(2):135-140.