Professional Information

Corticosteroids (Topical)

This monograph includes information on the following:

1) Alclometasone ^†
2) Amcinonide
3) Beclomethasone ^*
4) Betamethasone
5) Clobetasol
6) Clobetasone ^*
7) Clocortolone ^†
8) Desonide
9) Desoximetasone
10) Dexamethasone ^†
11) Diflorasone
12) Diflucortolone ^*
13) Flumethasone ^*
14) Fluocinolone
15) Fluocinonide
16) Flurandrenolide
17) Fluticasone ^†
18) Halcinonide
19) Halobetasol ^†
20) Hydrocortisone
21) Mometasone
22) Prednicarbate ^†
23) Triamcinolone

INN:
Beclomethasone— Beclometasone ^{21}
Flumethasone —Flumetasone ^{21}
Flurandrenolide—Fludroxycortide ^{21}
Halobetasol— Ulobetasol ^{21}
Hydrocortisone —Cortisol ^{21}

BAN:
Desoximetasone—Desoxymethasone ^{21}
Flurandrenolide—Flurandrenolone ^{21}
Hydrocortisone—Cortisol ^{21}

JAN:
Beclomethasone—Beclometasone ^{21}
Flumethasone—Flumetasone ^{21}
Flurandrenolide—Fluoxycortide ^{21}
Hydrocortisone—Cortisol ^{21}
Hydrocortisone buteprate—Hydrocortisone butyrate propionate ^{21}

VA CLASSIFICATION
Alclometasone
Topical
Primary: DE200

Amcinonide
Topical
Primary: DE200

Beclomethasone
Topical
Primary: DE200

Betamethasone
Topical
Primary: DE200

Clobetasol
Topical
Primary: DE200

Clobetasone
Topical
Primary: DE200

Clocortolone
Topical
Primary: DE200

Desonide
Topical
Primary: DE200

Desoximetasone
Topical
Primary: DE200

Dexamethasone
Topical
Primary: DE200

Diflorasone
Topical
Primary: DE200

Diflucortolone
Topical
Primary: DE200

Flumethasone
Topical
Primary: DE200

Fluocinolone
Topical
Primary: DE200

Fluocinonide
Topical
Primary: DE200

Flurandrenolide
Topical
Primary: DE200

Fluticasone
Topical
Primary: DE200

Halcinonide
Topical
Primary: DE200

Halobetasol
Topical
Primary: DE200

Hydrocortisone
Dental
Primary: OR900

Topical
Primary: DE200

Mometasone
Topical
Primary: DE200

Triamcinolone
Dental
Primary: OR900

Topical
Primary: DE200

Commonly used brand name(s): 9-1-1²⁰; Aclovate¹; Acticort 100²⁰; Aeroseb-Dex¹⁰; Aeroseb-HC²⁰; Ala-Cort²⁰; Ala-Scalp HP²⁰; Allercort²⁰; Alphaderm²⁰; Alphatrex⁴; Anusol-HC²⁰; Aristocort²³; Aristocort A²³; Aristocort C²³; Aristocort D²³; Aristocort R²³; Bactine²⁰; Barriere-HC²⁰; Beben⁴; Beta-HC²⁰; Beta-Val⁴; Betacort Scalp Lotion⁴; Betaderm⁴; Betaderm Scalp Lotion⁴; Betatrex⁴; Betnovate⁴; Betnovate-1/2⁴; Bio-Syn¹⁴; CaldeCORT Anti-Itch²⁰; CaldeCORT Light²⁰; Carmol-HC²⁰; Celestoderm-V⁴; Celestoderm-V/2⁴; Cetacort²⁰; Cloderm⁷; Cordran¹⁶; Cordran SP¹⁶; Cormax⁵; Cort-Dome²⁰; Cortacet²⁰; Cortaid²⁰; Cortate²⁰; Cortef²⁰; Cortef Feminine Itch²⁰; Corticaine²⁰; Corticreme²⁰; Cortifair²⁰; Cortoderm²⁰; Cortril²⁰; Cutivate¹⁷; Cyclocort²; Decaderm¹⁰; Decadron¹⁰; Decaspray¹⁰; Delacort²⁰; Delta-Tritex²³; Dermabet⁴; Dermacort²⁰; Dermarest DriCort²⁰; Dermatop²²; DermiCort²⁰; Dermovate⁵; Dermovate Scalp Lotion⁵; Dermtex HC²⁰; DesOwen⁸; Diprolene⁴; Diprolene AF⁴; Diprosone⁴; Drenison¹⁶; Drenison-1/4¹⁶; Ectosone Mild⁴; Ectosone Regular⁴; Ectosone Scalp Lotion⁴; Elocom²¹; Elocon²¹; Emo-Cort²⁰; Emo-Cort Scalp Solution²⁰; Epifoam²⁰; Eumovate⁶; Florone¹¹; Florone E¹¹; Fluocet¹⁴; Fluocin¹⁵; Fluoderm¹⁴; Fluolar¹⁴; Fluonid¹⁴; Fluonide¹⁴; Flurosyn¹⁴; Flutex²³; FoilleCort²⁰; Gly-Cort²⁰; Gynecort²⁰; Gynecort 10²⁰; Halog¹⁸; Halog-E¹⁸; Hi-Cor 1.0²⁰; Hi-Cor 2.5²⁰; Hyderm²⁰; Hydro-Tex²⁰; Hytone²⁰; Kenac²³; Kenalog²³; Kenalog in Orabase²³; Kenalog-H²³; Kenonel²³; LactiCare-HC²⁰; Lanacort²⁰; Lanacort 10²⁰; Lemoderm²⁰; Licon¹⁵; Lidemol¹⁵; Lidex¹⁵; Lidex-E¹⁵; Locacorten¹³; Locoid²⁰; Luxíq⁴; Lyderm¹⁵; Maxiflor¹¹; Maximum Strength Cortaid²⁰; Maxivate⁴; Metaderm Mild⁴; Metaderm Regular⁴; MyCort²⁰; Nerisone¹²; Nerisone Oily¹²; Novobetamet⁴; Novohydrocort²⁰; Nutracort²⁰; Occlucort⁴; Olux Foam⁵; Orabase-HCA²⁰; Oracort²³; Oralone²³; Pandel²⁰; Penecort²⁰; Pentacort²⁰; Pharma-Cort²⁰; Prevex B⁴; Prevex HC²⁰; Propaderm³; Psorcon¹¹; Rederm²⁰; Rhulicort²⁰; S-T Cort²⁰; Sarna HC 1.0%²⁰; Sential²⁰; Synacort²⁰; Synalar¹⁴; Synalar-HP¹⁴; Synamol¹⁴; Synemol¹⁴; Teladar⁴; Temovate⁵; Temovate E⁵; Temovate Scalp Application⁵; Texacort²⁰; Topicort⁹; Topicort LP⁹; Topicort Mild⁹; Topilene⁴; Topisone⁴; Topsyn¹⁵; Triacet²³; Triaderm²³; Trianide Mild²³; Trianide Regular²³; Triderm²³; Tridesilon⁸; Ultravate¹⁹; Unicort²⁰; Uticort⁴; Valisone⁴; Valisone Reduced Strength⁴; Valisone Scalp Lotion⁴; Valnac⁴; Westcort²⁰.

Other commonly used names are:

• Beclometasone —Beclomethasone

• Cortisol —Hydrocortisone

• Fludroxycortide —Flurandrenolide

• Flumetasone —Flumethasone

• Ulobetasol —Halobetasol

Note: For a listing of dosage forms and brand names by country availability, see Dosage Forms section(s).

^*Not commercially available in the U.S.

^†Not commercially available in Canada.

Category:

Corticosteroid (topical)—

anti-inflammatory, steroidal (topical)—

Indications

Note: Bracketed information in the Indications section refers to uses that are not included in U.S. product labeling.

General considerations
Topical corticosteroids are indicated to provide symptomatic relief of ^{09} inflammation and/or ^{59} pruritus associated with acute and chronic ^{100} ^{101} ^{116} ^{124} corticosteroid-responsive disorders. ^{23} ^{24} ^{38} ^{72} ^{75} ^{76} ^{77} ^{80} ^{81} ^{82} ^{83} ^{84} ^{85} ^{86} ^{87} ^{89} ^{90} ^{91} ^{92} ^{94} ^{95} ^{96} ^{100} ^{102} ^{104} ^{105} ^{106} ^{109} ^{111} ^{112} ^{114} ^{115} ^{116} ^{118} ^{124} ^{126} ^{127} ^{128} ^{129} ^{132} ^{135} ^{136} ^{137} ^{138} ^{139} ^{142} ^{144} ^{149} ^{414} ^{415} ^{417} ^{418} ^{426} ^{440} ^{441} ^{443} ^{444} ^{445} ^{446} ^{447} ^{448} ^{449} ^{450} ^{451} ^{452} ^{453} ^{454} ^{455} ^{456} ^{457} ^{458} ^{459} ^{460} ^{462} ^{463} ^{464}

The location of the skin lesion to be treated should be considered in selecting a formulation. ^{167} ^{169} In areas with thinner skin, such as facial, eye, and intertriginous areas, low-potency corticosteroid preparations are preferred for long-term therapy. ^{93} ^{160} ^{167} ^{358} Low- to medium-potency products may be used on the ears, trunk, arms, legs, and scalp. ^{93} ^{167} Medium- to very high–potency formulations may be required for treatment of dermatologic disorders in areas with thicker skin, such as the palms and soles. ^{93} Lotion, aerosol, and gel formulations are cosmetically better suited for hairy areas. ^{167}

The type of lesion to be treated should also be considered in product selection. For dry, scaly, cracked, thickened, or hardened skin, ointments of medium potency are often used. ^{93} ^{102} ^{104} ^{112} ^{114} ^{115} ^{116} ^{117} ^{120} ^{127} ^{132} ^{144} ^{183} ^{247} ^{251} Medium-potency lotions, aerosols, ^{167} or creams are preferred in treating moister, weeping lesions or areas or in treating conditions with intense inflammation. ^{93} ^{102} ^{112} ^{114} ^{115} ^{116} ^{117} ^{120} ^{127} ^{132} ^{144} ^{147} ^{167} ^{247} ^{251} ^{358} High- to very high–potency ointments may be required to treat hyperkeratotic or thick skin lesions. ^{93}

Accepted

Dermatitis, atopic, mild to moderate ^{07} ^{88} ^{93} ^{98} ^{104} ^{105} ^{112} ^{116} ^{126} ^{142} ^{143} ^{144} ^{147} ^{178} ^{181} ^{182} ^{247} ^{249} ^{250} ^{251}
Dermatitis, contact ^{07} ^{88} ^{93} ^{98} ^{100} ^{102} ^{104} ^{105} ^{112} ^{116} ^{126} ^{131} ^{135} ^{136} ^{137} ^{142} ^{143} ^{144} ^{147} ^{159} ^{181} ^{195} ^{247} ^{248} ^{249} ^{250} ^{251} ^{441}
Dermatitis, nummular, mild ^{60} ^{88} ^{93} ^{102} ^{104} ^{105} ^{116} ^{126} ^{143} ^{144} ^{147} ^{195} ^{248} ^{250}
Dermatitis, seborrheic, facial and intertriginous areas ^{07} ^{08} ^{77} ^{88} ^{93} ^{98} ^{100} ^{102} ^{104} ^{105} ^{116} ^{126} ^{135} ^{137} ^{142} ^{143} ^{144} ^{147} ^{160} ^{169} ^{195} ^{247} ^{248} ^{249} ^{250} ^{251} ^{395} ^{400} ^{441}
Dermatitis, other forms of, mild to moderate ^{07} ^{98} ^{100} ^{102} ^{104} ^{126} ^{135} ^{136} ^{137} ^{143} ^{144} ^{147} ^{247} ^{249} ^{251} ^{395} ^{437} ^{438} ^{441}
Dermatoses, inflammatory, other, mild to moderate ^{07} ^{10} ^{38} ^{72} ^{75} ^{98} ^{142} ^{143} ^{144} ^{145} ^{147} ^{159} ^{249} ^{251}
Intertrigo ^{60} ^{88} ^{93} ^{98} ^{102} ^{104} ^{105} ^{126} ^{159} ^{161} ^{247}
Lichen planus, facial and intertriginous areas ^{93} ^{98} ^{116} ^{160} ^{249}
Lupus erythematosus, discoid, facial and intertriginous areas ^{93} ^{116} ^{126} ^{135} ^{137} ^{160} ^{195} ^{247} ^{249}
Polymorphous light eruption ^{60} ^{88} ^{93} ^{98} ^{102} ^{104} ^{112}
Pruritus, anogenital ^{88} ^{89} ^{93} ^{98} ^{102} ^{104} ^{105} ^{116} ^{126} ^{133} ^{136} ^{142} ^{143} ^{144} ^{147} ^{248} ^{250} ^{441} ^{443}
Pruritus senilis ^{98} ^{185}
Psoriasis, facial and intertriginous areas ^{10} ^{88} ^{93} ^{98} ^{100} ^{102} ^{104} ^{105} ^{116} ^{126} ^{135} ^{137} ^{143} ^{144} ^{147} ^{160} ^{167} ^{170} ^{195} ^{249} ^{250} ^{441} or
Xerosis, inflammatory phase ^{88} ^{93} ^{195}—Topical corticosteroids of low to medium potency (see Table 1, Pharmacology/Pharmacokinetics ) are indicated in the treatment of corticosteroid-responsive dermatologic disorders. Occlusive dressings also may be required for chronic or severe cases of lichen simplex chronicus, psoriasis, eczema, atopic dermatitis, or chronic hand eczema. ^{104} ^{105} ^{106} ^{109} ^{126} ^{358} The more potent topical corticosteroids and/or occlusive dressings may be required for conditions such as discoid lupus erythematosus, lichen planus, granuloma annulare, psoriatic plaques, and psoriasis affecting the palms, soles, elbows, or knees. ^{398}

Alopecia areata ^{60} ^{88} ^{195}
Dermatitis, atopic, moderate to severe ^{162} ^{169} ^{182} ^{183} ^{195} ^{248}
Dermatitis, exfoliative, generalized ^{60} ^{93} ^{98} ^{102} ^{104} ^{105} ^{126} ^{143} ^{144} ^{147} ^{160}
Dermatitis, nummular, moderate to severe ^{60} ^{93} ^{102} ^{104} ^{105} ^{116} ^{126} ^{143} ^{144} ^{147} ^{195}
Dermatitis, other forms of, moderate to severe ^{93} ^{98} ^{100} ^{102} ^{104} ^{109} ^{126} ^{135} ^{137} ^{143} ^{144} ^{162} ^{169} ^{172} ^{175} ^{177} ^{181} ^{437} ^{438}
Dermatoses, inflammatory, other, moderate to severe ^{98} ^{142} ^{143} ^{144} ^{147} ^{183} ^{356}
Granuloma annulare ^{72} ^{126} ^{162} ^{169} ^{395}
Keloids, reduction of associated itching ^{163} ^{394} ^{395} ^{399}
Lichen planus ^{72} ^{88} ^{93} ^{98} ^{104} ^{105} ^{116} ^{160} ^{249}
Lichen simplex chronicus ^{10} ^{60} ^{61} ^{88} ^{93} ^{98} ^{100} ^{102} ^{104} ^{105} ^{112} ^{143} ^{144} ^{147} ^{181} ^{247} ^{248} ^{249} ^{250} ^{251} ^{401}
Lichen striatus ^{60} ^{88}
Lupus erythematosus, discoid and subacute cutaneous ^{72} ^{88} ^{93} ^{160} ^{162} ^{169} ^{195} ^{247} ^{358}
Myxedema, pretibial ^{60} ^{88}
Necrobiosis lipoidica diabeticorum ^{60} ^{88} ^{162} ^{163} ^{169} ^{394} ^{400} ^{397}
Pemphigoid ^{93} ^{162} ^{169} ^{195} ^{357}
Pemphigus ^{88} ^{162} ^{169}
Pityriasis rosea ^{93} ^{160} ^{373}
Psoriasis ^{10} ^{88} ^{93} ^{97} ^{98} ^{100} ^{102} ^{104} ^{105} ^{110} ^{116} ^{126} ^{135} ^{137} ^{143} ^{144} ^{147} ^{160} ^{162} ^{166} ^{167} ^{168} ^{169} ^{170} ^{171} ^{172} ^{173} ^{174} ^{176} ^{177} ^{179} ^{180} ^{183} ^{248} ^{249} ^{250} ^{297} ^{355}
Sarcoidosis ^{60} ^{88} or
Sunburn ^{395}—Topical corticosteroids of medium to very high potency (see Table 1, Pharmacology/Pharmacokinetics) are indicated in the treatment of corticosteroid-responsive dermatologic disorders. Systemic therapy with, or intralesional injection of, a corticosteroid may be required for some of the disorders, as determined by the type and severity of the condition or inadequate response to topical therapy. ^{143} Occlusive dressings also may be required for conditions such as discoid lupus erythematosus; bullous disorders; lichen planus; granuloma annulare; psoriatic plaques; and psoriasis affecting the palms, soles, elbows, or knees. ^{72} ^{104} ^{105} ^{106} ^{109} ^{121} ^{126} ^{183}

Oral lesions, inflammatory or ulcerative (treatment)—Hydrocortisone acetate and triamcinolone acetonide dental pastes are indicated for adjunctive treatment and temporary relief of symptoms associated with nonherpetic oral inflammatory and ulcerative lesions, including recurrent aphthous stomatitis. ^{96} ^{146} ^{250} ^{300} ^{431} [ Formulations of high potency gels and very high potency ointments also are used in the treatment of aphthous stomatitis.]¹ ^{389} ^{394} ^{395} ^{396} ^{397} ^{402}
—[These agents also are used to treat other gingival disorders, such as desquamative gingivitis and oral lichen planus when the diagnosis has been confirmed by biopsy testing. ^{160} ^{250} ^{300} ^{396} Gel formulations of high potency corticosteroids and dental triamcinolone are used in the treatment of lichen planus of the mucous membranes. ^{160}]¹
—[Other topical corticosteroids also are used to treat gingival disorders.]¹

[Phimosis]¹—Topical corticosteroids are indicated for the treatment of phimosis in boys.^{473}^{474}^{475}^{476}^{477}^{478}^{479}^{480}^{481}^{482}^{483}

Unaccepted
Medium to very high potency topical corticosteroids should not be used in the treatment of rosacea ^{11} ^{62} ^{148} ^{167} ^{249} ^{358} and perioral dermatitis. ^{11} ^{148} ^{249} ^{251} ^{435} ^{463} Although topical corticosteroids may initially reduce the burning and pustulation associated with rosacea, a severe rebound flare-up may occur upon discontinuance of the steroid. ^{167}

Topical corticosteroids should not be used in the treatment of acne. ^{11} ^{62} ^{148} ^{167} ^{249} ^{251}

Topical corticosteroids are not indicated for routine gingivitis, which should be treated by the removal of local causative factors and an improvement in oral hygiene.

Alclometasone cream or ointment should not be used in the treatment of diaper dermatitis. ^{10}

¹ Not included in Canadian product labeling.

Pharmacology/Pharmacokinetics

Note: The following table lists topical corticosteroid products available in the U.S. and/or Canada. A potency rank of Low, Medium, High, or Very High also is listed for each preparation. ^{401}
Products with a Low potency ranking have a modest anti-inflammatory effect and are safest for chronic application. These products also are the safest products for use on the face and intertriginous areas, with occlusion, and in infants and young children. ^{395} ^{396} ^{401}
Products with a Medium potency ranking are used in moderate inflammatory dermatoses. ^{401} Examples of conditions for which these products are frequently used include chronic eczematous dermatoses such as hand eczema and atopic eczema. ^{401} Medium potency preparations may be used on the face and intertriginous areas for a limited duration. ^{401}
High potency preparations are used in more severe inflammatory dermatoses. ^{401} Examples of conditions for which these products are frequently used include more severe eczematous dermatoses, lichen simplex chronicus, and psoriasis. ^{401} They may be used for an intermediate duration, or for longer periods in areas with thickened skin due to chronic conditions. ^{396} ^{401} High potency preparations also may be used on the face and intertriginous areas but only for a short treatment duration. ^{401}
Very High potency products are used primarily as an alternative to systemic corticosteroid therapy when local areas are involved. ^{401} Examples of conditions for which Very High potency products are frequently used include thick, chronic lesions caused by psoriasis, lichen simplex chronicus, and discoid lupus erythematosus. ^{401} There is a high likelihood of skin atrophy with the use of Very High potency preparations. They may be used for only a short duration of therapy and on small surface areas. ^{401} Occlusive dressings should not be used with these products. ^{401}

Generic drug name	Dosage Form(s)	Strength (%)	Potency Ranking
Alclometasone dipropionate
	Cream	0.05	Low ^{10}
	Ointment	0.05	Low ^{10}
Amcinonide
	Cream	0.1	High
	Lotion	0.1	High
	Ointment	0.1	High
Beclomethasone dipropionate
	Cream	0.025	Medium
	Lotion	0.025	Medium
	Ointment	0.025	Medium
Betamethasone benzoate
	Cream	0.025	Medium
	Gel	0.025	Medium
	Lotion	0.025	Medium
Betamethasone dipropionate
	Cream
	Diprolene AF	0.05	Very high
	Others	0.05	High
	Gel ^{434}
	Diprolene	0.05	Very high
	Lotion
	Diprolene	0.05	Very high
	Others	0.05	High
	Ointment
	Diprolene	0.05	Very high
	Others	0.05	High
	Topical aerosol	0.1	High
Betamethasone valerate
	Cream	0.01	Medium
	Cream	0.05	Medium
	Cream	0.1	Medium
	Foam	0.12	Medium
	Lotion	0.05	Medium
	Lotion	0.1	Medium
	Ointment	0.05	Medium
	Ointment	0.1	Medium
Clobetasol propionate
	Cream	0.05	Very high
	Ointment	0.05	Very high
	Solution	0.05	Very high
Clobetasone butyrate
	Cream	0.05	Medium
	Ointment	0.05	Medium
Clocortolone pivalate
	Cream	0.1	Low
Desonide
	Cream	0.05	Low
	Lotion ^{434}	0.05	Low
	Ointment	0.05	Low
Desoximetasone
	Cream	0.05	Medium
	Cream	0.25	High
	Gel	0.05	High
	Ointment	0.25	High
Dexamethasone
	Gel	0.1	Low
	Topical aerosol	0.01	Low
	Topical aerosol	0.04	Low
Dexamethasone sodium phosphate
	Cream	0.1 (phosphate)	Low
Diflorasone diacetate
	Cream	0.05	High
	Ointment
	Psorcon	0.05	Very high
	Others	0.05	High
Diflucortolone valerate
	Cream	0.1	Medium
	Ointment	0.1	Medium
Flumethasone pivalate
	Cream	0.03	Low
	Ointment	0.03	Low
Fluocinolone acetonide
	Cream	0.01	Medium
	Cream	0.025	Medium
	Cream	0.2	High
	Ointment	0.01	Medium
	Ointment	0.025	Medium
	Topical solution	0.01	Medium
Fluocinonide
	Cream	0.01	High
	Cream	0.05	High
	Gel	0.05	High
	Ointment	0.01	High
	Ointment	0.05	High
	Topical solution	0.05	High
Flurandrenolide
	Cream	0.0125	Low
	Cream	0.025	Medium
	Cream	0.05	Medium
	Lotion	0.05	Medium
	Ointment	0.0125	Low
	Ointment	0.025	Medium
	Ointment	0.05	Medium
	Tape	4 mcg/ cm	Medium
Fluticasone propionate
	Cream	0.05	Medium ^{434}
	Ointment	0.005	Medium ^{434}
Halcinonide
	Cream	0.025	High
	Cream	0.1	High
	Ointment	0.1	High
	Topical solution	0.1	High
Halobetasol propionate
	Cream	0.05	Very high ^{434}
	Ointment	0.05	Very high ^{434}
Hydrocortisone
	Cream	0.25	Low
	Cream	0.5	Low
	Cream	1	Low
	Cream	2.5	Low
	Lotion	0.25	Low
	Lotion	0.5	Low
	Lotion	1	Low
	Lotion	2	Low
	Lotion	2.5	Low
	Ointment	0.5	Low
	Ointment	1	Low
	Ointment	2.5	Low
	Topical aerosol solution	0.5	Low
	Topical spray solution	0.5	Low
	Topical solution	1	Low
	Topical solution	2.5	Low
Hydrocortisone acetate
	Cream	0.1	Low
	Cream	0.5	Low
	Cream	1	Low
	Lotion	0.5	Low
	Ointment	0.5	Low
	Ointment	1	Low
	Topical aerosol foam	1	Low
Hydrocortisone butyrate
	Cream	0.1	Medium
	Ointment	0.1	Medium
Hydrocortisone valerate
	Cream	0.2	Medium
	Ointment	0.2	Medium
Mometasone furoate
	Cream	0.1	Medium
	Lotion	0.1	Medium
	Ointment	0.1	Medium
Triamcinolone acetonide
	Cream	0.025	Medium
	Cream	0.1	Medium
	Cream	0.5	High
	Lotion	0.025	Medium
	Lotion	0.1	Medium
	Ointment	0.025	Medium
	Ointment	0.1	Medium
	Ointment	0.5	High
	Topical aerosol	0.015	Medium

Physicochemical characteristics:
Molecular weight—
    Alclometasone dipropionate: 521.05 ^{21}
    Amcinonide: 502.58 ^{20} ^{21}
    Beclomethasone dipropionate: 521.05 ^{21}
    Betamethasone: 392.47 ^{21}
    Betamethasone benzoate: 496.58 ^{21}
    Betamethasone dipropionate: 504.6 ^{21}
    Betamethasone sodium phosphate: 516.41 ^{21}
    Betamethasone valerate: 476.59 ^{21}
    Clobetasol propionate: 466.98 ^{21}
    Clobetasone butyrate: 478.99 ^{21}
    Clocortolone pivalate: 495.03 ^{21}
    Desonide: 416.52 ^{21}
    Desoximetasone: 376.47 ^{21}
    Dexamethasone: 392.47 ^{21}
    Dexamethasone sodium phosphate: 516.41 ^{21}
    Diflorasone diacetate: 494.54 ^{21}
    Diflucortolone valerate: 478.6 ^{188}
    Flumethasone pivalate: 494.58 ^{21}
    Fluocinolone acetonide: 452.5 ^{21}
    Fluocinolone acetonide, dihydrate: 488.53
    Fluocinonide: 494.54 ^{21}
    Flurandrenolide: 436.52 ^{21}
    Fluticasone propionate: 500.58 ^{21}
    Halcinonide: 454.97 ^{21}
    Halobetasol propionate: 484.97 ^{21}
    Hydrocortisone: 362.47 ^{21}
    Hydrocortisone acetate: 404.51 ^{21}
    Hydrocortisone buteprate: 488.62 ^{21}
    Hydrocortisone butyrate: 432.56 ^{21}
    Hydrocortisone valerate: 446.59 ^{21}
    Mometasone furoate: 521.44 ^{21}
    Prednicarbate: 488.58 ^{21}
    Triamcinolone acetonide: 434.51 ^{21}

Mechanism of action/Effect:

Corticosteroids diffuse across cell membranes and complex with specific cytoplasmic receptors. ^{164} ^{167} ^{300} These complexes then enter the cell nucleus, bind to DNA (chromatin), and stimulate transcription of messenger RNA (mRNA) and subsequent protein synthesis of various inhibitory enzymes responsible for the anti-inflammatory effects of topical corticosteroids. ^{132} ^{167} ^{194} ^{300} These anti-inflammatory effects include inhibition of early processes such as edema, fibrin deposition, capillary dilatation, movement of phagocytes into the area, and phagocytic activities. Later processes, such as capillary production, collagen deposition, and keloid formation also are inhibited by corticosteroids. ^{167} ^{194} ^{300} The overall actions of topical corticosteroids are catabolic. ^{132} ^{194} ^{300}

Factors that increase the clinical efficacy and potential for adverse effects ^{132} ^{167} of topical corticosteroids include enhancement of pharmacologic activity of the compound by altering molecular structure, ^{190} ^{300} increasing stratum corneum penetration of the compound, and increasing bioavailability of the compound from the vehicle. ^{193}

The pharmacologic activity of topical corticosteroids is increased by several changes in molecular structure. ^{190} ^{300} Addition of a 9-alpha-fluorine atom increases the anti-inflammatory glucocorticoid activity, but simultaneously increases undesired mineralocorticoid activity. ^{132} ^{167} ^{190} ^{300} Mineralocorticoid activity is diminished by addition of a 16-hydroxy or 16-methyl group. ^{132} ^{190} ^{300} Substitution or masking of 16- or 17-hydroxy groups with longer side chains such as acetonide, propionate, or valerate increases lipophilicity and subsequently stratum corneum penetration. ^{190} ^{300}

Dental paste in dental dosage forms acts as an adhesive vehicle for application of corticosteroids to oral mucosa. The vehicle also reduces pain by serving as a protective covering. ^{146} ^{281}

Absorption:

Absorbed systemically across the stratum corneum.

Stratum corneum penetration is primarily enhanced by increasing skin hydration and/or temperature, or by changes in molecular structure of the compound. ^{72} ^{75} ^{76} ^{77} ^{97} ^{98} ^{100} ^{102} ^{104} ^{105} ^{110} ^{111} ^{112} ^{113} ^{115} ^{116} ^{117} ^{118} ^{120} ^{124} ^{125} ^{126} ^{127} ^{129} ^{132} ^{133} ^{134} ^{135} ^{138} ^{139} ^{141} ^{142} ^{143} ^{144} ^{145} ^{146} ^{147} ^{167} ^{169} ^{190} ^{249} ^{251} ^{300} ^{390}

Hydrating the skin with occlusive dressings such as plastic wrap, a tight-fitting diaper or one covered with plastic pants, plastic tape, or dermatological patches can increase corticosteroid penetration by up to tenfold. ^{165} ^{300} Ointment bases inhibit evaporation of moisture from skin. ^{165} ^{167} ^{300} Intertriginous areas (axillae and groin) are self-occluding. Intertriginous areas and the face also have inherently thinner skin, are more macerated and therefore, allow for increased absorption. ^{93} ^{167} ^{247} ^{300} ^{358}

Absorption of topical corticosteroids has been greatly increased by altering the product vehicle ^{10} ^{28} or the drug substance itself. ^{165} ^{300} Vehicles containing substances that solubilize the corticosteroid enhance absorption. ^{193} Increasing the concentration of the drug increases skin penetration but also may increase wastage of the drug. ^{167} ^{300} ^{436} Decreasing drug particle size has been shown to increase topical bioavailability. ^{165}

Increased percutaneous absorption of corticosteroids also occurs when the skin or mucosa is abraded or inflamed, ^{10} ^{167} when body temperature is elevated, ^{117} with prolonged use, ^{10} ^{23} ^{24} ^{163} ^{251} or with extensive use. ^{10} ^{23} ^{24} ^{75} ^{77} ^{183}

There is some systemic absorption of topical corticosteroids through the oral mucosa; absorption increases with increased potency and prolonged use. ^{146}

Biotransformation:

Primarily in skin; once absorbed systemically, in the liver. ^{10} ^{22} ^{26} ^{261} Corticosteroids that contain substituted 17-hydroxyl groups or that are fluorinated are resistant to local metabolism in the skin. Repeated application results in a cumulative depot effect in the skin, ^{165} which may lead to a prolonged duration of action, increased side effects, and increased systemic absorption.

The following topical corticosteroids contain substituted 17-hydroxyl groups (S) and/or are fluorinated (F) compounds:

• Alclometasone dipropionate—S ^{10}

• Amcinonide—S, F ^{04}

• Beclomethasone dipropionate—S

• Betamethasone—F

• Betamethasone benzoate—S, F

• Betamethasone dipropionate—S, F ^{28}

• Betamethasone valerate—S, F

• Clobetasol propionate—S, F

• Clobetasone butyrate—S, F

• Clocortolone pivalate—S, F

• Desonide—S

• Desoximetasone—S (17-hydrogen), F

• Dexamethasone—F

• Dexamethasone sodium phosphate—F

• Diflorasone diacetate—S, F

• Diflucortolone valerate—F

• Flumethasone pivalate—F

• Fluocinolone acetonide—S, F

• Fluocinonide—S, F

• Flurandrenolide—S, F

• Fluticasone propionate—S, F ^{417} ^{418}

• Halcinonide—S, F

• Halobetasol propionate—S, F ^{414} ^{415}

• Hydrocortisone butyrate—S

• Hydrocortisone valerate—S

• Mometasone furoate—S

• Triamcinolone acetonide—S, F

Precautions to Consider

Carcinogenicity

Long-term animal studies to determine the carcinogenicity of topical corticosteroids have not been done. ^{05} ^{06} ^{10} ^{11} ^{12} ^{13} ^{14} ^{15} ^{17} ^{18} ^{19} ^{20} ^{22} ^{23} ^{24} ^{26} ^{27} ^{28} ^{29} ^{30} ^{31} ^{32} ^{33} ^{34} ^{35} ^{36} ^{37} ^{38} ^{39} ^{41} ^{42} ^{43} ^{44} ^{45} ^{46} ^{47} ^{48} ^{72} ^{75} ^{76} ^{414} ^{415} ^{417} ^{418} ^{426} ^{429} ^{440} ^{443}

Mutagenicity

Betamethasone—Betamethasone was found to be genotoxic in the in vitro human peripheral blood lymphocyte chromosome aberration assay with metabolic activation and in the in vivo mouse bone marrow micronucleus assay. ^{22}

Fluticasone—No mutagenicity was shown with fluticasone propionate in the Ames test, Escherichia coli fluctuation test, Saccharomyces cerevisiae gene conversion test, or Chinese hamster ovarian cell assay. ^{417} ^{418} Fluticasone was not clastogenic in mouse micronucleus or cultured human lymphocyte tests. ^{417} ^{418}

Halobetasol—Halobetasol propionate was not found to be genotoxic in the Ames/Salmonella assay, sister chromatid exchange test in Chinese hamster somatic cells, chromosome aberration studies of germinal and somatic cells of rodents, and a mammalian spot test to determine point mutations. ^{414} ^{415} ^{462} ^{463} It was found to be mutagenic in a Chinese hamster micronucleus test, and in a mouse lymphoma gene mutation assay in vitro . ^{414} ^{415}

Hydrocortisone and prednisolone—Studies on mutagenicity with hydrocortisone and prednisolone ^{10} ^{11} ^{29} ^{30} ^{31} ^{48} yielded negative results. ^{05} ^{06} ^{12} ^{13} ^{14} ^{15} ^{17} ^{18} ^{19} ^{20} ^{26} ^{27} ^{28} ^{32} ^{33} ^{34} ^{35} ^{36} ^{37} ^{38} ^{41} ^{42} ^{44} ^{45} ^{46} ^{47} ^{443}

Mometasone—No mutagenicity was shown with mometasone in the Ames test, mouse lymphoma assay, and a micronucleus test. ^{23} ^{24}

Pregnancy/Reproduction

Pregnancy—
Topical corticosteroids, especially the more potent ones, should not be used extensively, in large amounts, or for protracted periods in pregnant patients or in patients who are planning to become pregnant. ^{22} ^{28} ^{104} ^{105} ^{112} ^{113} ^{118} ^{126} ^{137} ^{138} ^{139} ^{141} ^{142} ^{143} ^{145} ^{248} ^{250} ^{261}

Adequate and well-controlled studies in humans have not been done. ^{10} ^{22} ^{28} ^{97} ^{98} ^{100} ^{101} ^{102} ^{104} ^{112} ^{113} ^{114} ^{115} ^{116} ^{117} ^{118} ^{120} ^{121} ^{122} ^{123} ^{124} ^{125} ^{126} ^{127} ^{129} ^{132} ^{133} ^{134} ^{135} ^{137} ^{138} ^{139} ^{141} ^{142} ^{143} ^{144} ^{145} ^{146} ^{147} ^{247} ^{248} ^{249} ^{250} ^{251} ^{443} ^{444} ^{445} ^{446} ^{447} ^{448} ^{449} ^{450} ^{451} ^{452} ^{453} ^{454} ^{455} ^{456} ^{457} ^{458} ^{459} ^{460} ^{462} ^{463} ^{464}

Studies in animals have shown that topical corticosteroids are systemically absorbed and may cause fetal abnormalities, especially when used in large amounts, with occlusive dressings, for prolonged periods of time, or if the more potent agents are used. ^{22} ^{443}

Betamethasone: A dose-related increase in fetal resorptions was observed in rabbits and mice given betamethasone dipropionate intramuscularly. ^{429} This effect was not observed in rats. ^{429} Teratogenic effects (umbilical hernia, cephalocele, cleft palate) were observed in rabbits when betamethasone dipropionate was administered intramuscularly. ^{429}

Desoximetasone: In studies in mice, rats, and rabbits, desoximetasone has been shown to be teratogenic and embryotoxic with subcutaneous or dermal use. ^{05} ^{432}

Fluticasone: In studies in mice, fluticasone was found to be teratogenic (cleft palate) with subcutaneous usage of doses approximately 14 and 45 times the usual human topical dose. ^{417} ^{418}

Halobetasol: In studies in rats and rabbits, halobetasol propionate administered systemically was shown to be teratogenic at doses 3 to 33 times the usual human topical dose. ^{414} ^{415} ^{462} ^{463} Cleft palate was observed in both species. ^{414} ^{415} ^{462} ^{463} Omphalocele was seen in rats only. ^{414} ^{415} Halobetasol propionate was shown to be embryotoxic in rabbits but not in rats. ^{414} ^{415}

Hydrocortisone dental dosage form: Studies have not been done in animals.

FDA Pregnancy Category C. ^{10} ^{22} ^{23} ^{24} ^{28} ^{72} ^{75} ^{76} ^{104} ^{247} ^{248} ^{249} ^{250} ^{261} ^{414} ^{415} ^{417} ^{418} ^{426} ^{429} ^{440} ^{441} ^{443} ^{444} ^{445} ^{446} ^{447} ^{448} ^{449} ^{450} ^{451} ^{452} ^{453} ^{454} ^{455} ^{456} ^{457} ^{458} ^{459} ^{460} ^{462} ^{463} ^{464}

Breast-feeding

It is not known whether topical corticosteroids are distributed into breast milk. ^{10} ^{22} ^{28} ^{72} ^{75} ^{76} ^{414} ^{415} ^{417} ^{418} ^{426} ^{429} ^{434} ^{443} However, problems in humans have not been documented. ^{104} ^{434}

Systemic corticosteroids are distributed into breast milk ^{10} ^{22} ^{28} ^{72} ^{75} ^{76} and may cause unwanted effects, such as growth suppression, in the infant. ^{10} ^{22} ^{434}

Topical corticosteroids should not be applied to the breasts prior to nursing. ^{65} ^{434}

Pediatrics

Children and adolescents have a large skin surface area to body weight ratio and less developed, thinner skin, which may result in absorption of greater amounts of topical corticosteroids compared with older patients. ^{05} ^{06} ^{10} ^{11} ^{12} ^{13} ^{14} ^{15} ^{17} ^{18} ^{19} ^{20} ^{22} ^{23} ^{24} ^{26} ^{27} ^{28} ^{29} ^{30} ^{31} ^{32} ^{33} ^{34} ^{35} ^{36} ^{37} ^{38} ^{41} ^{42} ^{43} ^{44} ^{45} ^{46} ^{47} ^{48} ^{72} ^{75} ^{76} ^{77} ^{182} ^{300} ^{361} ^{414} ^{415} ^{417} ^{418} ^{426} ^{429} Absorption also is greater in premature infants than in full term newborns, due to inadequate development of the stratum corneum. ^{165} ^{300}

Adrenal suppression, ^{10} ^{22} ^{28} ^{247} ^{249} Cushing's syndrome, ^{10} ^{22} ^{28} ^{63} ^{64} intracranial hypertension, ^{05} ^{06} ^{10} ^{11} ^{12} ^{13} ^{14} ^{15} ^{17} ^{18} ^{19} ^{20} ^{22} ^{23} ^{24} ^{26} ^{27} ^{28} ^{29} ^{30} ^{31} ^{32} ^{33} ^{34} ^{35} ^{36} ^{37} ^{38} ^{39} ^{41} ^{42} ^{43} ^{44} ^{45} ^{46} ^{47} ^{48} and growth retardation ^{10} ^{22} ^{28} ^{97} ^{104} ^{105} due to the systemic absorption of topical corticosteroids have been documented in children. ^{10} ^{28} ^{414} ^{415} ^{417} ^{418} ^{426} ^{429} Therefore, special care must be exercised when these agents are used in children and growing adolescents, ^{305} especially if factors that increase absorption are involved. ^{72} ^{75} ^{76} ^{77} ^{189} ^{195} It is recommended that only low-potency, unfluorinated topical corticosteroids that have a free 17-hydroxyl group be used in children or growing adolescents ^{305} unless there is a demonstrated need for one of the other topical corticosteroids. ^{162} ^{167} ^{182} ^{190}

Generally, pediatric therapy continuing for longer than 2 weeks and consisting of doses in excess of one daily application (with medium- or high-potency corticosteroids) or two daily applications (with low-potency corticosteroids) should be evaluated carefully by the physician. This is especially important if medication is applied to more than 5 to 10% of the body surface or if an occlusive dressing is used. A tight-fitting diaper or one covered with plastic pants may constitute an occlusive dressing. ^{72} ^{75} ^{76} ^{167} ^{247} ^{248}

Geriatrics

Although appropriate studies with topical corticosteroids have not been performed in the geriatric population, geriatrics-specific problems are not expected to limit the usefulness of topical corticosteroids in the elderly. However, elderly patients may be more likely to have pre-existing skin atrophy secondary to aging. Purpura and skin lacerations that may raise the skin and subcutaneous tissue from deep fascia may be more likely to occur with the use of topical corticosteroids in geriatric patients. ^{167} ^{248} ^{250} Therefore, topical corticosteroids should be used infrequently, for brief periods, or under close medical supervision in patients with evidence of pre-existing skin atrophy. ^{358} ^{363} Use of lower potency topical corticosteroids also may be necessary in some patients. ^{248} ^{250} ^{358} ^{363} ^{373}

Laboratory value alterations
The following have been selected on the basis of their potential clinical significance (possible effect in parentheses where appropriate)—not necessarily inclusive (» = major clinical significance):

With physiology/laboratory test values
Eosinophil count, total    (may be decreased as plasma cortisol concentration is decreased ^{167})

Glucose    (because of the intrinsic hyperglycemic activity of corticosteroids, blood and urine concentrations may be increased if significant absorption of the corticosteroid occurs ^{10} ^{23} ^{24} ^{72} ^{75} ^{76} ^{146})

Hypothalamic-pituitary-adrenal (HPA) axis function as assessed by:
Adrenocorticotropic hormone (ACTH, corticotropin) or
Cortisol, blood ^{10} ^{22} ^{93} ^{167} ^{172} ^{174} ^{183} ^{190} ^{192} or
Cortisol, urine (24-hour) ^{10} ^{362} or
17-hydroxycorticosteroids, urine (24-hour) ^{10} ^{167}    (may be decreased if significant absorption of the corticosteroid occurs, especially in children ^{10} ^{23} ^{24} ^{72} ^{75} ^{76})

Medical considerations/Contraindications
The medical considerations/contraindications included have been selected on the basis of their potential clinical significance (reasons given in parentheses where appropriate)— not necessarily inclusive (» = major clinical significance).

Risk-benefit should be considered when the following medical problems exist
Allergy to corticosteroids ^{10} ^{22} ^{26} ^{27} ^{28} ^{29} ^{255} ^{261}
Infection at treatment site ^{04} ^{10} ^{22} ^{23} ^{24} ^{97} ^{98} ^{100} ^{101} ^{102} ^{104} ^{105} ^{110} ^{111} ^{112} ^{113} ^{114} ^{115} ^{116} ^{117} ^{118} ^{120} ^{121} ^{122} ^{123} ^{124} ^{125} ^{126} ^{127} ^{128} ^{129} ^{132} ^{133} ^{134}

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