13.4 Topical corticosteroids

Mild corticosteroid

ChoiceDrugDosage
1st choiceHydrocortisone 0.5% and 1%; cream and ointmentDose:
Apply 1-2 times daily

Moderately potent corticosteroid

ChoiceDrugDosage
1st choiceClobetasone butyrate 0.05% (Eumovate®); cream and ointmentDose:
Apply 1-2 times daily
2nd choiceBetamethasone valerate 0.025% (Betnovate-RD®); cream and ointmentDose:
Apply 1-2 times daily
or
Fluocinolone acetonide 0.00625% (Synalar 1 in 4 Dilution®); cream and ointmentDose:
Apply 1-2 times daily

Potent corticosteroid

ChoiceDrugDosage
1st choiceBetametasone valerate 0.1% (Betnovate®); cream, ointment, scalp applications, lotionDose:
Apply 1-2 times daily
or
Hydrocortisone butyrate 0.1% (Locoid®) cream, lipocream, ointment, scalp lotion, topical emulsion (Locoid Crelo®)Dose:
Apply 1-2 times daily
or
Fluocinolone acetonide 0.025% (Synalar®); cream, gel and ointmentDose:
Apply 1-2 times daily
or
Mometasone furoate 0.1% (Elocon®)Dose:
Apply once daily

Very potent corticosteroid

ChoiceDrugDosage
1st choiceClobetasol propionate 0.05% (Dermovate®); cream, ointment, scalp applicationDose:
Apply 1-2 times daily for up to 4 weeks; max 50g of 0.05% preparation per week

Prescribing Notes

  • Topical corticosteroids provide symptomatic relief in eczema and are safe in the short term. The potency should be matched to the disease severity and the affected site; weaker corticosteroids should be used on the face and flexures.
  • Parents/carers need reassurance about the value of topical steroids used appropriately.
  • Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected (unless the infection is being treated).
  • In order to avoid confusion between clobetasol propionate 0.05% (Dermovate®) and clobetasone butyrate 0.05% (Eumovate®), these products should be prescribed by BRAND name.
  • As a rough guide, steroid use should be limited to a few days to a week for acute eczema and up to 4-6 weeks to gain initial remission for chronic eczema.
  • Initially, topical steroids should be applied once daily, if no benefit is seen after 7-10 days, change to twice daily for a further 7-10 days.
  • In order to minimize side-effects, it is important to apply once to twice daily to affected areas only. The weakest steroid that controls the disease effectively should be chosen; this may involve either a step-up approach (less potent to more potent) or a step-down approach (more potent to less potent). Reduce strength and frequency of topical corticosteroid application as the condition settles.
  • A general rule of thumb is that emollient use should exceed steroid use by 10:1 in terms of quantities used for most patients.
  • Topical steroids should not be used to provide an emollient effect.
  • Emollients and topical steroids should not be applied at the same time (a minimum interval of 20 minutes should be left if possible); patient preference will dictate whether emollient or topical corticosteroid is applied first.
  • Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
  • The risk of systemic side-effects increases with prolonged use on thin, inflamed or raw skin surfaces, use in flexures, or use of more potent corticosteroids. Only mild corticosteroids should generally be used on the face.
  • There is no benefit in increasing the strength of hydrocortisone from 1% to 2.5%: instead, patients should be moved up the steroid potency ladder, i.e. to a moderately potent steroid.
  • Topical use of potent corticosteroids (betamethasone valerate 0.1% and fluocinolone acetonide 0.025%) on widespread psoriasis can lead to systemic as well as to local side-effects.  It is reasonable, however, to prescribe a mild to moderate topical corticosteroid for a short period (2-4 weeks) for flexural and facial psoriasis and to use a more potent corticosteroid such as betamethasone valerate 0.1% or fluocinolone acetonide 0.025% for psoriasis on the scalp, palms or soles.
  • Patients prescribed very potent topical corticosteroids (clobetasol propionate 0.05%) should be reviewed regularly (at least monthly) and the preparation should not be prescribed on repeat prescription, except on specialist advice.
  • Rarely, very potent corticosteroids (e.g. clobetasol) may be indicated in resistant severe eczema on the hands and feet of adults, again with regular review of use.
  • Fludroxycortide tape can be used for localised areas that also require occlusion. It is applied for 12 hours each day.

Choice of formulation

  • Water-miscible corticosteroid creams are suitable for moist areas, e.g. axillae or groin or for weeping lesions.
  • Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required (occlusion increases both efficacy and side-effects).
  • Gels/lotions may be useful when minimal application to a large or hair-bearing area is required or for the treatment of exudative lesions.
  • The inclusion of urea or salicylic acid increases the penetration of the corticosteroid.