What are topical steroids?
Topical steroids are safe and effective anti-inflammatory preparations used to control eczema/dermatitis and many other skin conditions. They are available in creams, ointments, solutions and other vehicles.
Topical steroids are also called topical corticosteroids, glucocorticosteroids, and cortisones.
The effects of topical steroids on various cells in the skin are:
- Potency of topical steroids
The potency of topical steroids depends on:
- The specific molecule
- Amount that reaches the target cell
- Absorption through the skin (0.25%–3%)
There is little point in diluting a topical steroid, as their potency does not depend much on concentration. After the first 2 or 3 applications, there is no additional benefit from applying a topical steroid more than once daily.
Steroids are absorbed at different rates depending on skin thickness.
- The greatest absorption occurs through thin skin of eyelids, genitals, skin creases, when potent topical steroids are best avoided.
- The least absorption occurs through the thick skin of palms and soles, where mild topical steroids are ineffective.
Absorption also depends on the vehicle in which the topical steroid is delivered and is greatly enhanced by occlusion.
Several formulations are available to suit the type of skin lesion and its location. Creams and lotions are general purpose and are the most popular formulations.
- Most suitable formulation for dry, non-hairy skin
- No requirement for preservative, reducing risk of irritancy and contact allergy
- Occlusive, increasing risk of folliculitis and miliaria
Gel or solution
- Useful in hair-bearing skin
- Has an astringent (drying) effect
- Stings inflamed skin
As a general rule, use the weakest possible steroid that will do the job. It is often appropriate to use a potent preparation for a short time to ensure the skin condition clears completely.
Which topical steroids are available in New Zealand?
Topical steroids are medicines regulated by Health Authorities. They are classified according to their strength. The products listed here are those available in New Zealand in January 2016.
| Very potent or superpotent (up to 600 times as potent as hydrocortisone)
| Potent (100–150 times as potent as hydrocortisone)
| Moderate (2–25 times as potent as hydrocortisone)
What are the side effects of topical steroids?
Side effects are uncommon or rare when topical steroids are used appropriately under medical supervision. Topical steroids may be falsely blamed for a sign when underlying disease or another condition is responsible (eg hypopigmentation, which is in fact post-inflammatory).
Internal side effects similar to those due to systemic steroids (Cushing syndrome) are rarely reported from topical steroids, and only after long-term use of large quantities of topical steroid (eg > 50 g of clobetasol propionate or > 500 g of hydrocortisone per week).
Cutaneous side effects
Local side effects of topical steroids may arise when potent topical steroids are applied daily for long periods of time (months). Most reports of side effects describe prolonged use of unnecessarily potent topical steroids for inappropriate indications.
- Skin thinning (atrophy)
- Stretch marks (striae) in armpits or groin
- Easy bruising (senile/solar purpura) and tearing of the skin.
- Enlarged blood vessels (telangiectasia)
- Localised increased hair thickness and length (hypertrichosis)
Topical steroids can cause, aggravate or mask skin infections, eg impetigo, tinea, herpes simplex, malassezia folliculitis and molluscum contagiosum. Note: topical steroids remain the first-line treatment for infected eczema.
Potent topical steroids applied for weeks to months or longer can lead to:
- Periorificial dermatitis (common)
- Steroid rosacea
- Topical corticosteroid withdrawal syndrome
- Pustular psoriasis
Stinging frequently occurs when a topical steroid is first applied, due to underlying inflammation and broken skin. Contact allergy to steroid molecule, preservative or vehicle is uncommon, but may occur after the first application of the product, or after many years of its use.
Localised pustular psoriasis
Ocular side effects
Topical steroids should be used cautiously on eyelid skin. Potentially, their excessive use over weeks to months might lead to glaucoma or cataracts.
How to use topical steroids
Topical steroid is applied once daily (usually at night) to inflamed skin for a course of 5 days to several weeks. After that, it is usually stopped, or the strength or frequency of application is reduced.
Emollients can be applied before or after the application of topical steroid, to relieve irritation and dryness or as a barrier preparation. Infection may need additional treatment.
Fingertip units guide the amount of topical steroid to be applied to a body site. One unit describes the amount of cream squeezed out of its tube onto the volar aspect of the terminal phalanx of the index finger.
The quantity of cream in a fingertip unit varies with age:
- Adult male: one fingertip unit provides 0.5 g
- Adult female: one fingertip unit provides 0.4 g
- Child aged 4 years: approximately 1/3 of adult amount
- Infant 6 months to 1 year: approximately 1/4 of adult amount
The amount of cream that should be used varies with the body part:
- One hand: apply 1 fingertip unit
- One arm: apply 3 fingertip units
- One foot: apply 2 fingertip units
- One leg: apply 6 fingertip units
- Face and neck: apply 2.5 fingertip units
- Trunk, front & back: 14 fingertip units
- Entire body: about 40 units
- Mooney E, Rademaker M, Dailey R, Daniel BS, Drummond C, Fischer G, Foster R, Grills C, Halbert A, Hill S, King E, Leins E, Morgan V, Phillips RJ, Relic J, Rodrigues M, Scardamaglia L, Smith S, Su J, Wargon O, Orchard D. Adverse effects of topical corticosteroids in paediatric eczema: Australasian consensus statement. Australas J Dermatol. 2015 Mar 6. doi: 10.1111/ajd.12313. [Epub ahead of print] PubMed PMID: 25752907.
- MIMS Online accessed 22 February 2014
- Can topical steroids be applied at the same time as emollients? Medicines Q&As. NHS
- Corticosteroids (Ch. 25). In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Bolognia Textbook of Dermatology. 2nd ed. Mosby Elsevier publishing; 2008.
On DermNet NZ:
- Systemic steroids
- Intralesional steroids
- Topical corticosteroid contact allergy
- Topical corticosteroid withdrawal syndrome
- Topical Corticosteroids Medical Education (UK)
- Consumer medicine information and data sheets – Medsafe
- Drugs, Herbs and Supplements – MedlinePlus
- Topical corticosteroids PDF – A quick guide to potency, structural class and cross-reactivity, from Connetics.
- International Topical Steroid Awareness Network
Books about skin diseases:
See the DermNet NZ bookstore
New Zealand approved datasheets are the official source of information for these prescription medicines, including approved uses and risk information. Check individual New Zealand datasheets on the Medsafe website.