Corticosteroid preparations (topical)

Page last reviewed: 13/07/2011

Topical corticosteroid is a general term that refers to any sort of cream, gel or ointment containing corticosteroids (see below). People sometimes use the term 'steroid creams' when talking about topical corticosteroids.

Topical corticosteroids are widely used in the treatment of inflammatory skin conditions such as:

  • atopic eczema - a chronic skin condition where the skin becomes itchy, reddened, dry and cracked
  • psoriasis - a skin condition that causes red, flaky, crusty patches of skin covered with silvery scales

Corticosteroids

Corticosteroids are a synthetic (artificial) version of hormones that are made by the adrenal gland. Hormones are powerful chemicals that have a wide range of effects on the functions of the body.

The main purpose of topical corticosteroids is to reduce skin inflammation and irritation. They cannot cure the conditions that trigger these types of symptoms, but they can provide temporary relief when you have a particularly bad flare-up of symptoms.

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 cause dryness of 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 weepy (leaking liquid)
  • ointments - liquids that contain high levels of oil, meaning they can be quite greasy; they moisturise the skin and are therefore 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

Strengths of topical corticosteroids

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

  • mild
  • moderate
  • potent
  • very potent

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

  • thinning of the skin
  • the skin becoming more vulnerable to infection
  • changes in skin colour

Safety

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

High levels of potent topical corticosteroids can disrupt the normal hormonal balance in the body and cause more wide-ranging side effects, such as:

  • hyperglycaemia - an increase in blood sugar levels
  • high blood pressure (hypertension)
Adrenal glands
The adrenal glands are two small, triangular-shaped glands that sit on top of the kidneys and produce adrenaline, steroid hormones and male and female sex hormones.
Inflammation
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

Corticosteroids and anabolic steroids

The steroids contained in topical corticosteroids should not be confused with the sort of steroids that are sometimes used (illegally) by bodybuilders and athletes. These are anabolic steroids.

Anabolic steroids contain an entirely different type of hormone that can help to stimulate tissue growth, particularly muscle tissue. If they are used correctly, topical corticosteroids do not have any effect on muscle growth or development.

Page last reviewed: 13/07/2011

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

Inflammation

When a part of your body is affected by infection, your immune system will respond by flooding the area with infection-fighting antibodies. The antibodies limit the spread of infection and kill off the virus, bacteria or fungus that is responsible for the infection. The immune system is the body's natural defence system against illness and infection.

However, these chemicals will cause the affected area of the body to become swollen, warm and, in the case of your skin, reddened. This is known as inflammation.

Inflammation is usually a useful biological process. But there are times where the immune system malfunctions and triggers inflammation even though no infection has occurred. This 'misfiring' of the immune system is the main cause of many common skin conditions, such as atopic eczema and psoriasis.

How topical corticosteroids work

There are four main ways that topical corticosteroids help to treat skin conditions such as atopic eczema. They:

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

Page last reviewed: 13/07/2011

Topical corticosteroids are used to relieve symptoms of skin inflammation, irritation and itching that are caused by inflammatory skin conditions. Conditions that can be treated with topical corticosteroids include:

  • 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), such as certain metals
  • discoid lupus erythematosus - a type of lupus that usually only affects the skin (most people with the more common form of lupus have additional symptoms, such as fatigue and joint pain)
  • more serious cases of nappy rash 
  • lichen planus - a poorly understood skin condition that causes an itchy, non-infectious rash
  • skin irritation that has been caused by insect stings or insect bites
  • psoriasis - dead skin cells build up on the outer layer of skin (epidermis) and cause symptoms such as red, flaky or crusty patches of skin that are covered with silvery scales
  • seborrhoeic dermatitis - this causes the skin of the scalp and other parts of the body to become flaky, resulting in symptoms such as dandruff

Page last reviewed: 13/07/2011

General use

Topical corticosteroids should not be applied to areas of your skin that are currently being affected by an ongoing bacterial, fungal or viral infection. This is because they could make the symptoms of the skin infection worse.

Pregnancy

Mild, moderate and potent 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, if you have applied topical corticosteroid to your breasts you should wash it off before feeding your baby.

It is uncertain whether very potent topical corticosteroids are safe to use while breastfeeding. As a precaution their use is not recommended.

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 very 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).

Page last reviewed: 13/07/2011

Potency

The potency of a medication is a measurement of how powerful the effect of the medication will be. There are four classes of potency for topical corticosteroids. They are:

  • mild topical corticosteroids, such as hydrocortisone; they are used to treat mild cases of skin inflammation, such as those caused by an insect bite 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; they are 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; they are used on a short-term basis to treat particularly severe 'flare-ups' of symptoms that do not respond to other treatments

To reduce the risk of side effects, your GP will prescribe the least potent corticosteroid that they think is necessary to relieve your symptoms.

Finger tips units

The dosage of topical corticosteroids is measured in finger tip units (FTUs). A 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.

A FTU is about 500mg. It should be enough to treat an area of skin that is 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 GP can advise you about this.

Frequency

For most conditions, you will only need to apply topical corticosteroids to affected areas of skin 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 safely indefinitely to treat chronic (long-term) skin conditions, such as atopic eczema. However, most people will 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 should not be used for more than seven days. If treatment is still required after this time, referral to a dermatologist (skin care specialist) is usually recommended.

Combining topical corticosteroids and emollients

Some people with skin conditions also use emollients. These are topical treatments that are designed to prevent the skin becoming too dry, scaly and itchy.

If you are using both topical corticosteroids and emollients it is recommended that you apply the emollient first. Then wait 30 minutes before applying the topical corticosteroid.

Page last reviewed: 13/07/2011

Topical corticosteroids rarely cause serious side effects if they are used as instructed. Factors 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 who are over 70 have a greater risk because their skin tends to be thinner than other age groups

Types of side effects

Two categories of side effects can occur after treatment with topical corticosteroids. They are:

  • local side effects -  these affect the patch of skin being treated
  • systemic side effects - these occur in other parts of the body

These are described in more detail below.

Local side effects

Local side effects are the most common type of side effect. 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 that 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 that they will be permanent, although they will probably become less noticeable over time.

Systemic side effects

Systemic side effects are rarer than local side effects. They usually occur only if you do not follow the proper instructions about how to apply topical corticosteroids.

Systemic side effects occur because the steroids contained in the corticosteroid become absorbed into the blood stream and begin to 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 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 that is caused by having very 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

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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