Topical corticosteroids

Topical corticosteroid is a term refering to any sort of cream, gel or ointment containing corticosteroids. You may have heard them called ‘steroid creams’.

Topical corticosteroids are widely used to treat inflammatory skin conditions such as atopic eczema and psoriasis.

Their main purpose is to reduce skin inflammation and irritation. They cannot cure the conditions that trigger these symptoms, but they can provide temporary relief during a particularly bad flare-up of symptoms.

Read more about when topical corticosteroids are used and how topical corticosteroids work.

For information about steroid tablets and sprays, see our page on corticosteroids.

Types of topical corticosteroids

There are five main types of topical corticosteroids:

• solutions – water- or alcohol-based liquids that are non-greasy and easy to apply, but they can sometimes dry out the skin
• lotions – similar to solutions but thicker; they are often recommended to treat larger areas of skin or hairy areas
• creams – thicker than lotions and often recommended when the affected skin has become moist or is weeping
• ointments – liquids containing high levels of oil, which can make them greasy; they are usually recommended to treat skin that has become dry and scaly
• gels – a more solidified, jelly-like substance, often used to treat areas of the body that are very hairy, such as the scalp

Topical corticosteroids are also available in different strengths. The strength is determined by the amount of steroids the medicine contains. They can be:

• mild
• moderate
• potent
• very potent

Read more about dosage of topical corticosteroids.

Your doctor will usually prescribe the lowest strength of corticosteroid necessary to control your symptoms. This reduces the risk of any adverse side effects, such as the skin:

• thinning
• becoming more vulnerable to infection
• changing colour

Read more about the side effects of topical corticosteroids.

Safety

If used as directed, topical corticosteroids are a very safe treatment. Serious side effects usually only occur if excessive amounts of potent or very potent corticosteroids are applied.

However, there are some things to consider while taking topical corticosteroids.

High levels of potent topical corticosteroids can disrupt the hormonal balance in the body, leading to side effects, such as:

• hyperglycaemia – an increase in blood sugar levels
• high blood pressure (hypertension)

Topical corticosteroids are used to relieve the symptoms of skin inflammation, irritation and itching caused by inflammatory skin conditions.

Eczema

Topical corticosteroids may be used to treat types of eczema, including:

• atopic eczema – an allergic skin condition
• contact dermatitis – where the skin becomes inflamed due to an adverse reaction to an irritant, such as dust or an allergen (a substance that causes an allergic reaction)
• discoid eczema – a long-term condition that causes skin to become itchy, red, dry and cracked

Topical corticosteroids may also be prescribed to treat infected eczema, along with antibiotics.

Emollients are often prescribed to treat eczema and may be prescribed to use with topical corticosteroids if treating severe eczema.

Other conditions

Topical corticosteroids may also be used to treat:

• discoid lupus erythematosus – a type of lupus that usually only affects the skin
• serious cases of nappy rash
• lichen planus – a poorly understood skin condition that causes an itchy, non-infectious rash
• skin irritation caused by insect bites or stings
• psoriasis – causes dead skin cells to build up on the outer layer of skin, leading to red, flaky or crusty patches of skin
• seborrhoeic dermatitis – causes the skin to become flaky, leading to symptoms such as dandruff

Topical corticosteroids rarely cause serious side effects if they are used as instructed.

Things that increase your risk of getting side effects include:

• the potency (strength) of the topical corticosteroid
• the length of treatment – the longer you use a topical corticosteroid, especially on a daily basis, the greater the risk
• the area of skin being treated – the larger the area you are treating with a topical corticosteroid, the greater the risk
• your age – young children and people aged over 70 have a greater risk because their skin tends to be thinner than other age groups

Types of side effects

Side effects can affect the patch of skin being treated, known as local side effects, or they can affect other parts of the body, known as systemic side effects.

Local side effects

Local side effects are the most common. They usually occur on the face, in folds of skin and in areas that have been treated many times during the past months or years.

Local side effects include:

• burning or stinging of the skin – this is a common side effect that usually occurs when you start treatment; it improves as your skin gets used to the medication
• worsening of a pre-existing skin infection
• thinning of the skin – this can make the affected skin more vulnerable to damage; for example, you may bruise more easily than normal
• acne, or worsening of existing acne
• rosacea – a condition that causes the face to become red and flushed
• changes in skin colour – this is usually more noticeable in people with black or brown skin
• excessive hair growth on the area of skin being treated
• contact dermatitis – some people find they have a mild allergic reaction to the substances in a particular topical corticosteroid, which results in skin irritation
• stretch marks – these are narrow, streak-like lines that can develop on the surface of the skin

These local side effects should disappear after you have finished your treatment with corticosteroids. However, if you have stretch marks, it is likely they will be permanent, though they will probably become less noticeable over time.

Systemic side effects

Systemic side effects are rare and usually occur only if you do not apply topical corticosteroids as instructed.

Systemic side effects occur because the steroids become absorbed into the blood stream and affect other parts of the body, such as the adrenal gland (a gland that produces many of the body’s natural steroids).

Systemic side effects are usually mild but can include:

• swelling of the legs due to a build-up of fluid
• high blood pressure (hypertension)
• a drop in calcium levels in the body (hypocalcaemia) which can cause symptoms such as muscle cramps, shortness of breath and seizures (fits)
• bone damage
• decreased growth in children
• Cushing’s syndrome (see below)

Cushing’s syndrome is a rare condition caused by having high levels of steroid hormones in your blood. Symptoms of Cushing’s syndrome include:

• rapid weight gain
• changes to the skin, such as thinning of your skin
• mood changes, such as feeling depressed or anxious

Topical corticosteroids work by reducing inflammation and helping to control the symptoms of several skin conditions, such as atopic eczema and dermatitis.

Topical corticosteroids:

• block some of the effects of the chemicals used by the immune system to trigger the process of inflammation
• make the immune system less sensitive, meaning it is less likely to cause symptoms that affect the skin
• help to regulate the production of new skin cells – this can be useful in treating certain skin conditions, such as psoriasis, where new skin cells are produced too quickly
• narrow the blood vessels in the affected areas of skin – reducing the amount of inflammatory chemicals sent to the skin

Inflammation

To understand how topical corticosteroids work, it is useful to learn more about the biological processes that cause inflammation.

When a part of your body becomes infected, your immune system responds by flooding the area with infection-fighting antibodies. The antibodies limit the spread of infection and kill off the virus, bacteria or fungus responsible for the infection.

However, this process causes the affected area to become swollen, warm and, in the case of your skin, reddened. This is known as inflammation.

Inflammation is usually a helpful biological process. However, there are times when the immune system malfunctions and triggers inflammation even though there is no infection. This ‘misfiring’ of the immune system is the main cause of many common skin conditions, such as atopic eczema and psoriasis.

Topical corticosteroids are also split into four classes of potency and measured in finger tip units (FTUs).

Potency

The potency of a medication is a measurement of how powerful the effect of the medication will be.

The four classes of potency for topical corticosteroids are:

• mild topical corticosteroids, such as hydrocortisone; used to treat mild cases of skin inflammation, such as insect bites or contact dermatitis
• moderate topical corticosteroids, such as clobetasone butyrate; they treat more troublesome skin conditions, such as atopic eczema or severe cases of nappy rash
• potent topical corticosteroids, such as betamethasone dipropionate; used to treat skin conditions, such as psoriasis or seborrhoeic dermatitis, which do not respond to other treatments
• very potent topical corticosteroids, such as clobetasol propionate; used on a short-term basis to treat severe ‘flare-ups’ of symptoms that do not respond to other treatments

To reduce the risk of side effects, your doctor will prescribe the least potent corticosteroid necessary to relieve your symptoms.

Finger tips units

An FTU is the amount of topical corticosteroid needed to squeeze a line from the tip of an adult finger to the first crease of the finger.

An FTU is about 500mg. It should be enough to treat an area of skin double the size of the flat of your hand with your fingers together.

The recommended dosage in terms of FTUs will depend on what part of the body is being treated. This is because the skin is thinner in certain parts of the body and more sensitive to the effects of corticosteroids.

For adults, the recommended FTUs to be applied in one single dose are:

• 0.5 FTU for genitalia
• 1 FTU for hands, elbows and knees
• 1.5 FTUs for the feet, including the soles
• 2.5 FTUs for the face and neck
• 3 FTUs for the scalp
• 4 FTUs for the hands, arms and buttocks
• 8 FTUs for the legs and trunk (the main section of the body, excluding the arms, legs and head)

For children, the recommended FTUs will depend on their age. Your doctor can advise you about this.

Frequency

For most conditions, you will only need to apply topical corticosteroids once or twice a day.

Length of treatment

The recommended length of treatment will depend on the condition being treated and the strength of the topical corticosteroid being used.

Mild to moderate topical corticosteroids can usually be used indefinitely to treat chronic (long-term) skin conditions, such as atopic eczema. However, most people only need treatment when they have a flare-up of symptoms. They will not need to use a topical corticosteroid every day.

Potent and very potent topical corticosteroids are often prescribed for a shorter period of time. If treatment is required for a long period of time, it is likely you will be referred to a dermatologist (skin care specialist).

There are several cautions to consider when using topical corticosteroids.

Infections

Topical corticosteroids should not be applied to infected skin. They could make the symptoms of the skin infection worse.

Pregnancy

Mild or moderate topical corticosteroids are considered safe to use during pregnancy. However, using potent topical corticosteroids during pregnancy is not usually recommended. Research has found that they increase the risk of giving birth to a baby with a low birth weight.

Breastfeeding

Mild, moderate and potent topical corticosteroids are also considered safe to use when breastfeeding. However, you should wash off any steroid cream applied to your breasts before feeding your baby.

As a precaution, very potent topical corticosteroids are not recommended to use while breastfeeding because their safety is uncertain.

Children

Children can safely use mild to moderate topical corticosteroids. Potent and very potent topical corticosteroids are not usually recommended, particularly in very young children, because they carry a greater risk of causing side effects than in adults.

However, exceptions can be made if your child has severe symptoms and it is felt that the benefit of treatment outweighs the risks of side effects. For example, potent topical corticosteroids are sometimes recommended for treating cases of severe atopic eczema, usually under the supervision of a dermatologist (skin care specialist).