Corticosteroids were first made available for general use around 1950.
How to choose a steroid
The best result is obtained when the correct strength is matched with a specific diagnosis and anatomic location. Essentially, weaker topical steroids are utilized for thin-skinned and sensitive areas, especially areas under occlusion, such as the armpit, groin, buttock crease, breast folds. Weaker steroids are used on the face, eyelids, diaper area, perianal skin, and intertrigo of the groin or body folds. Moderate steroids are used for atopic dermatitis, nummular eczema, xerotic eczema, lichen sclerosis et atrophicus of the vulva, scabies (after scabiecide) and severe dermatitis. Strong steroids are used for psoriasis, lichen planus, discoid lupus, chapped feet, lichen simplex chronicus, severe poison ivy exposure, alopecia areata, nummular eczema, and severe atopic dermatitis in adults.
How to use a topical steroid
To prevent tachyphylaxis, a topical steroid is often prescribed to be used on a week on, week off routine. Some recommend using the topical steroid for 3 consecutive days on, followed by 4 consecutive days off. Weak topical steroid are reserved for the eyelids, facial skin, body folds, axillae, groin, genitals, and perineal region. Moderate topical steroids are used in wider unoccluded parts of the body like the trunk, arms, and legs. Strong topical steroids are used in limited skin areas to minimize systemic side effects. They are indicated for thick-skinned areas like the palms, soles of feet, and certain dermatitis such as lichen planus and psoriasis of the limbs.
Long-term use of topical steroids can lead to secondary infection with fungus or bacteria (see tinea incognito), skin atrophy, telangiectasia (prominent blood vessels), skin bruising and fragility.
The use of the finger tip unit may be helpful in guiding how much topical steroid is required to cover different areas of the body.
Side effects of topical steroids
Lower arm of a 47 year old female showing skin damage due to topical steroid useDiabetes mellitusOsteoporosis
Allergic contact dermatitis (see steroid allergy)
Rebound effect: Abrupt withdrawal of these medications can lead to aggressive recurrence of the condition.
Overuse of topical steroid can cause dermatitis. Complete withdrawal of topical steroid use can eliminate dermatitis.
Perioral dermatitis: This is a rash that occurs around the mouth and the eye region that has been associated with topical steroids.
Ocular effects: Topical steroid drops are frequently used after eye surgery but can also raise intra-ocular pressure (IOP).
Tachyphylaxis: The acute development of tolerance to the action of a drug after repeated doses. Significant tachyphylaxis can occur by day 4 of therapy. Recovery usually occurs after 3 to 4 days rest. This has led to therapies such as 3 days on, 4 days off; or one week on therapy, and one week off therapy.
Vehicle-related adverse effects
Other local adverse effects: These include facial hypertrichosis, folliculitis, miliaria, genital ulcers, and granuloma gluteale infantum. Long term use has resulted in Norwegian scabies, Kaposi's sarcoma, and other unusual dermatosis.
Soft steroids are topical steroids with a low rate of side effects in relation to their anti-inflammatory potency. These include hydrocortisone aceponate, hydrocortisone buteprate, methylprednisolone aceponate, mometasone furoate and prednicarbate.
USA systemThe USA system utilizes 7 classes, which are classified by their ability to constrict capillaries. Class I is the strongest, or superpotent. Class VII is the weakest and mildest
Very potent: up to 600 times stronger than hydrocortisone
Clobetasol propionate 0.05% (Dermovate)
Betamethasone dipropionate 0.25% (Diprolene)
Halobetasol proprionate 0.05% (Ultravate, Halox)
Diflorasone diacetate 0.05% (Psorcon)
Fluocinonide 0.05% (Lidex)
Halcinonide 0.05% (Halog)
Amcinonide 0.05% (Cyclocort)
Desoximetasone 0.25% (Topicort)
Triamcinolone acetonide 0.5% (Kenalog, Aristocort cream)
Mometasone furoate 0.1% (Elocon ointment)
Fluticasone propionate 0.005% (Cutivate)
Betamethasone dipropionate 0.05% (Diprosone)
Fluocinolone acetonide 0.01-0.2% (Synalar, Synemol, Fluonid)
Hydrocortisone valerate 0.2% (Westcort)
Hydrocortisone butyrate 0.1% (Locoid)
Flurandrenolide 0.05% (Cordran)
Triamcinolone acetonide 0.1% (Kenalog, Aristocort A ointment)
Mometasone furoate 0.1% (Elocon cream, lotion)
Triamcinolone acetonide 0.1% (Kenalog, Aristocort cream, lotion)
Fluticasone propionate 0.05% (Cutivate cream)
Desonide 0.05% (Tridesilon, DesOwen ointment)
Fluocinolone acetonide 0.025% (Synalar, Synemol cream)
Hydrocortisone valerate 0.2% (Westcort cream)
Prednicarbate 0.05% (Aclovate cream, ointment)
Triamcinolone acetonide 0.025% (Aristocort A cream, Kenalog lotion)
Fluocinolone acetonide 0.01% (Capex shampoo, Dermasmooth)
Desonide 0.05% (DesOwen cream, lotion)
The weakest class of topical steroids. Has poor lipid permeability, and can not penetrate mucous membranes well.
Hydrocortisone 2.5% (Hytone cream, lotion, ointment)
Hydrocortisone 1% (Many over-the-counter brands)
Most other countries, such as the United Kingdom, Germany, the Netherlands, New Zealand, recognize only 4 classes. In New Zealand I is the strongest, while in Continental Europe, class IV is regarded as the strongest.
Very potent (up to 600 times as potent as hydrocortisone)
Clobetasol propionate (Dermovate Cream/Ointment, Exel Cream)
Betamethasone dipropionate (Diprosone OV Cream/Ointment, Diprovate Cream)
Potent (50-100 times as potent as hydrocortisone)
Betamethasone valerate (Beta Cream/Ointment/Scalp Application, Betnovate Lotion/C Cream/C Ointment, Daivobet 50/500 Ointment, Fucicort)
Betamethasone dipropionate (Diprosone Cream/Ointment, Diprovate Cream)
Diflucortolone valerate (Nerisone C/Cream/Fatty Ointment/Ointment)
Hydrocortisone 17-butyrate (Locoid C/Cream/Crelo Topical Emulsion/Lipocream/Ointment/Scalp Lotion)
Mometasone furoate (Elocon Cream/Lotion/Ointment)
Methylprednisolone aceponate (Advantan Cream/Ointment)
Moderate (2-25 times as potent as hydrocortisone)
Clobetasone butyrate (Eumovate Cream)
Triamcinolone acetonide (Aristocort Cream/Ointment, Viaderm KC Cream/Ointment, Kenacomb Ointment)
Hydrocortisone 0.5-2.5% (DermAid Cream/Soft Cream, DP Lotion-HC 1%, Skincalm, Lemnis Fatty Cream HC, Pimafucort Cream/Ointment)
Japan rates topical steroids from 1 to 5, with 1 being strongest.
The highlighted steroids are often used in the screening of allergies to topical steroid and systemic steroids. When one is allergic to one group, one is allergic to all steroids in that group.
Hydrocortisone, hydrocortisone acetate, cortisone acetate, tixocortol pivalate, prednisolone, methyprednisolone, and prednisone
Triamcinolone acetonide, triamcinolone alcohol, amcinonide, budesonide, desonide, fluocinonide, fluocinolone acetonide, and halcinonide
Betamethasone, betamethasone sodium phosphate, dexamethasone, dexamethasone sodium phosphate, and fluocortolone
Hydrocortisone-17-butyrate, hydrocortisone-17-valerate, aclometasone dipropionate, betamethasone valerate, betamethasone dipropionate, prednicarbate, clobetasone-17-butyrate, clobetasol-17-propionate, fluocortolone caproate, fluocortolone pivalate, and fluprednidene acetate