Topical steroids

Topical steroids are aerosols, creams, gels, lotions, solutions, and tapes that contain corticosteroids (often abbreviated to steroids) which are designed to be applied externally to the scalp or the skin, depending on the condition being treated.

Corticosteroids control inflammation by mimicking naturally occurring corticosteroid hormones produced by our adrenal glands, which are two small glands that sit on top of our kidneys. In addition to reducing inflammation (redness and swelling) in the area that they are applied, topical corticosteroids also suppress the immune response, reduce cell turnover, and constrict (narrow) blood vessels.

What are topical steroids used for?

Topical steroids of low to medium potency may be used for the treatment of various skin disorders that respond to corticosteroids such as:

• atopic dermatitis (mild-to-moderate)
• contact dermatitis
• discoid lupus erythematosus of the face and skin folds (intertriginous areas)
• dry skin
• insect bites
• intertrigo
• itching confined to small areas of skin
• itching of the anogenital regions
• lichen planus of the face and intertriginous areas
• nummular dermatitis
• polymorphous light eruption
• psoriasis of the face and intertriginous areas
• seborrheic dermatitis of the face and intertriginous areas.

More potent topical corticosteroids may be used for the treatment of:

• Alopecia areata
• Atopic dermatitis (resistant)
• Discoid lupus erythematosus
• Lichen planus
• Granuloma annulare
• Psoriatic plaques and psoriasis that affects the palms, soles, elbows, or knees
• Severe hand eczema
• Severe poison ivy.

Generally, the weakest effective steroid should be used; however, some doctors may choose to use a more potent topical steroid initially for the first few days.

Are there any differences between topical steroids?

Topical steroids come in various potencies (strengths), ranging from very high potency (Class 1) to low potency (Class 7).

In some instances, absorption of different formulations containing the same active ingredient can vary (for example, betamethasone ointment is absorbed better than betamethasone cream) which can also affect potency.

Skin thickness also affects absorption.

• The skin of the eyelids, genitals, and skin creases is thin and potent topical steroids should be avoided.
• The skin of the palms and soles is thick and mild topical steroids are usually ineffective.

Absorption (and potency) is greatly enhanced by occlusion (covering the area with impermeable or semi-impermeable dressings).

Topical steroids are sometimes combined with other ingredients, such as antifungal or antibacterial agents. Combination antibacterial/corticosteroid preparations should only be used short-term (for less than one week) to reduce the risk of antimicrobial resistance developing.

Augmented preparations are those that have been modified so that they are absorbed through the skin faster.

Very high potency (Class 1)

These topical corticosteroids are up to 600 times more potent than topical hydrocortisone.

Potent (Class 2)

These topical corticosteroids are 100-150 times more potent than topical hydrocortisone.

Upper medium potency (Class 3)

These topical corticosteroids are up to 25 times more potent than topical hydrocortisone.

Medium potency (Class 4 and 5)

These topical corticosteroids are between 2 and 25 times more potent than topical hydrocortisone.

Mild (Class 6)

These topical corticosteroids are slightly more potent than topical hydrocortisone.

Least potent (Class 7)

Hydrocortisone is the least potent topical corticosteroid.

Note that potency charts vary depending on the source. This grouping of potencies is based on the best effort accumulation of data.

Are topical steroids safe?

Serious side effects are uncommon or rare when topical corticosteroids are used exactly as directed and for the time intended, but may include:

• Cushing syndrome: Rare, but the risk is higher if large quantities of a topical corticosteroid (>50g/week of clobetasol propionate or >500g/week of hydrocortisone) are used long-term
• Glaucoma or cataracts caused by excessive use of topical steroids near the eye.

Topical steroids should not be confused with anabolic steroids often abused by body-builders to increase muscle mass.

For a complete list of severe side effects, please refer to the individual drug monographs.

What are the side effects of topical steroids?

Common side effects reported with topical steroids include:

• Easy bruising and tearing of the skin
• Enlarged blood vessels (telangiectasia)
• Folliculitis (inflammation of the hair follicles) and miliaria (sweat rash): ointments
• Increased hair thickness and length in the area of application (hypertrichosis)
• Skin thinning
• Stinging or inflamed skin: creams
• Stretch marks (striae) especially in the armpits or groin.

Side effects associated with more potent topical steroid use include:

• Perioral dermatitis (also called “Muzzle rash”). Consists of small, red, pus-filled bumps and mild peeling around the mouth
• Steroid rosacea: A rosacea-like condition near the middle of the face. Can worsen when the topical steroid is discontinued
• Pustular psoriasis: Clearly defined raised bumps filled with pus
• Topical corticosteroid withdrawal: Symptoms include red burning skin, swelling, or pimples after discontinuation of the topical corticosteroid.

Topical corticosteroids can also mask the symptoms of infections caused by bacteria, fungi, or viruses.

Note that some potent topical steroids have been found illegally in some cosmetic products purchased over-the-counter or via the internet, resulting in steroid-dependent dermatitis and rosacea.

For a complete list of side effects, please refer to the individual drug monographs.