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Corticosteroids - topical (skin), nose, and eyes - Management
Basis for recommendation

  • Frequency of application
    • The frequency of application of topical corticosteroids has been the subject of a National Institute for Health and Clinical Excellence (NICE) Technology Appraisal that identified 10 randomized controlled trials (RCTs). The evidence suggested that, overall, there was little difference in effectiveness between once-daily and more frequent application of topical corticosteroids, although a difference could not be ruled out [NICE, 2004].
      • Taking into account cost-effectiveness information, NICE recommends that topical corticosteroids should be prescribed 'for application only once or twice daily'.
    • CKS recommends that, on a practical basis, most people should use topical corticosteroids once daily at first, and increase to twice daily only if the condition does not respond adequately [Williams, 2007].
      • A total of 10 RCTs compared once daily application with more frequent use of topical corticosteroids within the same potency group, for eczema. None of the studies found clear evidence that application more than once a day produced better overall clinical outcomes.
  • The recommendation to use topical corticosteroids in bursts of 3–7 days is based on published expert opinion [MeReC, 1999; Williams, 2005].
  • Combining topical corticosteroids and emollients
    • CKS found no controlled studies investigating the efficacy of combining topical corticosteroids and emollients. CKS recommends that when both treatments are being used, the emollient should be used first, followed by the topical corticosteroid, preferably after waiting for 30 minutes.
    • NICE states that 'a short interval (several minutes) should be left between application of a topical corticosteroid and an emollient, where practicable' [National Collaborating Centre for Women's and Children's Health, 2007].
    • The clinical guideline Best practice in emollient therapy published by the International Skin Care Nursing Group, states that emollients should be allowed to absorb before topical corticosteroids are applied (the skin should be moist or slightly tacky, but not slippery) [Dermatology UK, 2007]. This is because:
      • Application of corticosteroid immediately on top of, or before, an emollient may dilute the product and transfer corticosteroid to areas that do not require treatment.
    • The British National Formulary advises that mixing topical preparations on the skin should be avoided where possible; several minutes should elapse between application of different preparations [BNF 59, 2010].
    • Some experts recommend that the corticosteroid should be applied first. This is also a reasonable strategy, provided the emollient is not applied too quickly (particularly on top of corticosteroid ointment), diluting the corticosteroid. Waiting for 1 hour is suggested by some experts.
  • Finger-tip units (FTUs) and children

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