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13.4 Topical corticosteroids

Mild corticosteroid

ChoiceDrug
1st choiceHydrocortisone 1% cream and ointment

Prescribing notes

  • Hydrocortisone 0.5% has a limited role but where required please prescribe the cream (hydrocortisone 0.5% ointment is very high cost (£44 for 15g – Feb 23)
  • Hydrocortisone 2.5% cream and 2.5% ointment are also very high cost. Furthermore, 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
  • Please refer to further topical corticosteroid prescribing notes below

Moderately potent corticosteroid

ChoiceDrug

 

 

 

1st choice

Betamethasone valerate 0.025% (Betnovate-RD®); cream and ointment

or

Clobetasone butyrate 0.05% (Eumovate®); cream and ointment*

Prescribe by brand name

*Do not prescribe the 15g OTC  pack due to high cost

or
Fluocinolone acetonide 0.00625% (Synalar 1 in 4 Dilution®); cream and ointment

Potent corticosteroid

ChoiceDrug

 

 

1st choice

Betametasone valerate 0.1% (Betnovate®); cream, ointment, scalp applications, lotion
or
Fluocinolone acetonide 0.025% (Synalar®); cream, gel and ointment
or

Mometasone furoate 0.1%; cream, ointment, scalp lotion

Very potent corticosteroid

ChoiceDrug
1st choice

Clobetasol propionate 0.05% (Dermovate®); cream, ointment, scalp application

Prescribe by brand name

Prescribing Notes

  • Topical corticosteroids provide symptomatic relief in atopic dermatitis (atopic 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
  • Topical corticosteroids should be used for a limited time until settled and/or reviewed after an agreed interval. Once a clinical response is seen, withdraw the corticosteroid gradually to avoid rebound
  • 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 also chosen to reduce the risk of topical steroid withdrawal reactions, see MHRA Drug Safety Update September 2021. A step-up approach (less potent to more potent) or a step-down approach (more potent to less potent) may be involved. 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
  • 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
  • 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
  • Patients receiving long term treatment (several weeks) with a potent or very potent topical corticosteroid should be advised to carry a steroid emergency card

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

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