• Topical corticosteroids are effective and have few adverse effects if they are used appropriately.
• The choice of topical corticosteroid depends on the condition being treated (and its stage), the area of the body that is affected, and the age of the person.
• Condition being treated and its stage — mild forms of dermatitis may only require a mild topical corticosteroid whereas psoriasis may require a more potent topical corticosteroid.
• Prescribe the least potent steroid that relieves the symptoms, and an appropriate quantity.
• If the treatment is for a flare up of disease activity, taper the treatment by using a less potent steroid once the flare up is under control.
• The person's age — children and elderly people are more susceptible to the adverse effects of topical corticosteroids because they have a thinner epidermis. Elderly people also have decreased dermal collagen (due to age and sun damage).
• Area of body being treated
• Areas where the skin is thin or flexural (such as the face, scrotum, groin, axillae, and submammary area) usually require a weak or moderately-potent corticosteroid.
• Areas where the skin is thick, due to either site (palms of the hands and soles of the feet) or from constant scratching (lichenification), usually require more potent preparations.
• Consider prescribing an emollient with the topical corticosteroid (to moisturize the skin).

Theses recommendations are based on published expert opinion [Coulson, 1996; Menter et al, 2009] and the British National Formulary [BNF 59, 2010].

• The length of treatment depends on the condition being treated.
• Generally, potent topical corticosteroids should not be used regularly for more than 7 days. If treatment is indicated for longer than 7 days, consider seeking specialist advice.
• Supervise repeat prescriptions for topical corticosteroids and review the person regularly (every 6–12 months, depending on the individual, their condition, and the potency of the topical corticosteroid).
• If the symptoms do not improve after 3–7 days, reassess the condition and consider other potential causes:
• Infection — such as impetigo, herpes simplex, or tinea corporis, which can be worsened by topical corticosteroids. Investigate, and treat with the appropriate anti-infective drug.
• Hypersensitivity reaction — consider switching to a corticosteroid with a different active ingredient or refer the person to a dermatologist if there is any doubt as to the reason for the reaction.
• Non-adherence — this could be due to concerns about the safety of steroids. Reassure the person that adverse effects are rare when topical steroids are applied thinly and for a short period.
• Tolerance — consider switching to another topical corticosteroid of the same potency.

These recommendations are based on a drug reference database [Sweetman, 2009], and published expert opinion [Dermatology UK, 2007; Menter et al, 2009].

• Contact sensitivity can develop, both to the preservatives and to the steroid molecule; it may be difficult to distinguish this from worsening of the condition being treated [MeReC, 1999].
• The recommendation to supervise repeat prescriptions for topical corticosteroids and review the person regularly, is based on what CKS considers to be good clinical practice.

• Topical corticosteroids are available in four potencies: mildly potent, moderately potent, potent, and very potent (see Table 1 for more details). Prescribe the least potent preparation which is effective, and avoid dilution if possible.
• The potency of topical corticosteroids is determined by the amount of vasoconstriction they produce. However, potency can be affected by several factors.

• The potency of a topical corticosteroid can be affected by:
• The degree to which it inhibits inflammation.
• The formulation — ointments are more potent than creams.
• The presence of other ingredients (for example urea or salicylic acid), which may increase the potency of the topical corticosteroid.
• The salt of the steroid (for example hydrocortisone is a mild steroid, but hydrocortisone butyrate is a potent steroid).
• Using it under occlusion, which increases the risk of systemic absorption and adverse effects.
• Fluorination — fluorinated corticosteroids (such as Dermovate^®, Haelan^®, Metosyn^®, and Cutivate^®) have been modified to increase their potency; this increases the risk of adverse effects.

• Information regarding the potency of topical corticosteroids is taken from the British National Formulary [BNF 59, 2010].
• The factors that determine the potency of topical corticosteroids are based on published expert opinion [MeReC, 1998], the British National Formulary [BNF 59, 2010], and a drug reference database [Sweetman, 2009].
• Using topical corticosteroids under occlusion increases the risk of systemic absorption and adverse effects [Sweetman, 2009].

• Topical corticosteroids are available in several formulations, including creams, ointments, lotions, gels, tapes, mousses, and solutions.
• The choice of formulation depends on the condition being treated, its severity and location, and the person's preference.
• Solutions
• Solutions are low viscosity, alcohol- or water-based liquids.
• They are easy to apply and are non-greasy.
• They are very drying if alcohol is the base, and can sting sore skin.
• Lotions
• Lotions are similar to solutions, but thicker.
• They are useful for treating large or hairy areas, and for treating exudative lesions.
• Creams
• Creams are thicker than lotions and are suitable for moist or weepy lesions.
• They are moisturizing without being greasy. Many people prefer them, especially for use on the face and palms of the hands.
• Ointments
• Ointments are preferred for dry, lichenified, or scaly conditions.
• They have a more prolonged emollient effect and tend to increase the potency of the corticosteroid.
• They are less likely to cause irritation as they are usually preservative-free.
• Gels and mousses
• Gels are thicker than solutions, and can be drying.
• Mousses are stable, non-greasy foams.
• Gels and mousses can be useful for scalp conditions.
• Tapes/bandages
• Occlusive polythene or hydrocolloid dressings increase the absorption of the steroid, and increase the risk of adverse effects.
• They should only be used under supervision for a short period of time, and for areas of very thick skin (such as the palms of the hands and soles of the feet).
• Topical corticosteroids are also available as compound preparations, which contain other substances such as:
• Antibacterials and antifungals — for infected skin.
• Salicylic acid, calcipotriol, or coal tar — for psoriasis and other dry skin conditions.
• Some of these substances (for example urea and salicylic acid) may increase the penetration of the corticosteroid.

These recommendations are based on published expert opinion [Coulson, 1996; MeReC, 1999; Menter et al, 2009].

• The choice of formulation depends on the condition being treated, its severity and location, and the person's preference [Coulson, 1996; Menter et al, 2009].
• Ointments are preferred for dry, lichenified, or scaly conditions. They have a more prolonged emollient effect and tend to increase the potency of the corticosteroid. They are also less likely to cause irritation as they are usually preservative-free [BNF 59, 2010].
• Tapes — occlusive polythene or hydrocolloid dressings increase the absorption of the steroid, and increase the risk of adverse effects. They should only be used under supervision for a short period of time, and for areas of very thick skin [BNF 59, 2010].
• The description of the formulations is from a textbook [Warner and Camisa, 2001; Wolverton, 2001].

• A thin layer of topical corticosteroid should be applied once or twice daily, adjusting the potency to control symptoms. For many conditions, once-daily application is usually sufficient.
• The corticosteroid should typically be used in bursts of 3–7 days in order to achieve control. Once a clinical response is seen, withdraw gradually. Some improvement may be seen within 2–3 days.
• If an emollient is being used, instruct the person to apply this first and then wait 30 minutes before applying the topical corticosteroid (that is, after the emollient has been fully absorbed).
• Most products are supplied with an information leaflet specifying the number of finger-tip units (FTUs) needed to treat specific body areas.
• One FTU is the length of cream or ointment expelled from the tube equivalent to the distance from the tip of the adult index finger to the first crease. One FTU is about 500 mg and is sufficient to treat a skin area about twice that of the flat of the hand with the fingers together.
• See Finger tip units (FTUs) for adults and Finger tip units (FTUs) for children for the approximate amount of topical corticosteroid that should be applied to different areas of the body.

• The finger-tip unit (FTU) is measured on an adult index finger.
• The approximate amount of topical corticosteroid that should be applied to children, for each area of the body, is listed in Table 1.

• The approximate amount of topical corticosteroid that should be applied to adults, for each area of the body, is listed in Table 1.

• 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
• This recommendation is based on published expert opinion [Long et al, 1998; MeReC, 1999].

• It is important that the appropriate quantity of topical corticosteroid is prescribed (to avoid undertreatment).
• For suitable quantities of topical corticosteroid creams and ointments to prescribe, assuming the person is applying treatment twice a day for 2 weeks, see Table 1.
• For the weekly dose of topical corticosteroids unlikely to cause systemic adverse effects in adults, see Table 2.

These recommendations are based on published expert opinion [Coulson, 1996] and the British National Formulary [BNF 59, 2010].

• Some CKS experts reviewers consider undertreatment to be an 'adverse effect' of topical corticosteroids.
• Undertreatment is a significant problem in primary care. It is caused by several factors, including under-prescribing and failure to use a sufficient quantity [Beattie and Lewis-Jones, 2003].

• Withdraw long-term topical corticosteroid treatment gradually. Abrupt withdrawal can cause a relapse or rebound of the condition being treated (for example psoriasis or eczema). Reddening of the skin (rebound erythroderma) has also been (rarely) reported.
• Once a clinical response has been seen, taper the dose of corticosteroid. The following options can be considered:
• Step down to a lower-potency corticosteroid.
• Use a lower-potency corticosteroid with other topical treatments (such as vitamin D preparation or coal tar in psoriasis).
• Use a lower-potency corticosteroid intermittently.

This recommendation is based on a drug reference database [Sweetman, 2009].

• Flares of eczema may occur if steroids are stopped abruptly. Topical steroids should be withdrawn gradually, decreasing the potency in a stepwise manner [MeReC, 1999].
• Some CKS experts reviewers consider gradual withdrawal to be unnecessary, and may adversely influence compliance (especially when treating children).
• Options for withdrawal of topical corticosteroids are based on published expert opinion [Coulson, 1996; MeReC, 1999; Menter and Griffiths, 2007; van de Kerkhof et al, 2008; Menter et al, 2009].

• Contraindications
• Avoid topical corticosteroids in people with:
• Bacterial, fungal, or viral skin lesions.
• Rosacea.
• Perioral dermatitis.
• Acne.
• Ulcerations.
• Topical corticosteroids should not be used indiscriminately for itching.
• Cautions
• Potent topical corticosteroids should generally not be used on sensitive areas (including the face, axillae, and genitals).

• Contraindications
• These recommendations are based on published expert opinion [MeReC, 1999] and a drug reference database [Sweetman, 2009].
• Topical corticosteroids should be avoided on infected skin (unless the infection is being treated) [MeReC, 1999].
• Cautions
• These recommendations are based on published expert opinion [Coulson, 1996; MeReC, 1999] and a drug reference database [Sweetman, 2009].

• Pregnancy
• Mildly potent, moderately potent, and potent topical corticosteroids, if used correctly, are considered suitable for use during pregnancy.
• Very potent topical corticosteroids may be associated with low birthweight. If a very potent corticosteroid is being considered for use during pregnancy, seek specialist advice.
• Breastfeeding
• Mildly potent, moderately potent, and potent topical corticosteroids are considered suitable for use during breastfeeding.
• The risk of systemic absorption can be minimized by using the weakest potency possible, for the shortest period of time.
• If the topical corticosteroid is applied to the breasts, it should be washed off before breastfeeding to prevent the infant ingesting it.

Pregnancy

These recommendations are based on published expert opinion [Schaefer et al, 2007; Weatherhead et al, 2007].

• A Cochrane systematic review identified two cohort studies and five case-control studies (with 659,675 participants) of women who were exposed to topical corticosteroids during pregnancy [Chi et al, 2009].
• These studies had several methodological weaknesses, which made the results difficult to interpret. The authors of the review considered the studies to be of low or very low quality.
• From these data, no association was found between use of topical corticosteroids during pregnancy and congenital abnormality, pre-term delivery, or stillbirth.
• Some evidence suggested that very potent topical corticosteroids might be associated with low birthweight.

Breastfeeding

• Potent corticosteroids are considered suitable for use during breastfeeding [WHO, 2002].

• When used correctly, topical corticosteroids rarely cause serious adverse effects.
• The likelihood of adverse effects is directly related to:
• Duration of treatment — long-term treatment is likely to result in systemic absorption.
• Area of the skin being treated — treating large areas of skin increases the risk of absorption.
• Condition of the skin — absorption is greatest in thin, inflamed skin.
• Potency of the topical corticosteroid — the greater the potency, the greater the risk of absorption.
• Occlusion — use of topical corticosteroids under occlusion increases the risk of systemic absorption.
• Age — children and elderly people are more susceptible to the adverse effects of topical corticosteroids because they have a thinner epidermis. Elderly people also have reduced dermal collagen (due to age and sun damage).
• Local adverse effects are more common. They mostly occur on the face, in skin folds, and in areas that are treated over the long term. Local adverse effects include:
• Transient burning or stinging — this is common, especially in the first 2 days of application on untreated, inflamed skin. It does not usually warrant a change of treatment, as it improves as the skin responds to treatment.
• Worsening and spreading of untreated infection.
• Thinning of the skin — the skin improves over a period after stopping treatment.
• Permanent stretch marks.
• Allergic contact dermatitis — due to the corticosteroid or the excipients.
• Acne (or worsening of existing acne) or rosacea.
• Mild depigmentation — usually reversible.
• Excessive hair growth at the site of application (hypertrichosis).
• Systemic adverse effects are rare, but may include:
• Adrenal suppression.
• Cushing's syndrome.
• Growth retardation in children.

• The likelihood of adverse effects is based on published expert opinion [Coulson, 1996] and the British National Formulary [BNF 59, 2010].
• Children (especially babies) are more susceptible to the adverse effects of topical corticosteroids as they tend to have a thinner epidermis [Coulson, 1996]. However, these concerns should not lead to undertreatment [BNF 59, 2010].
• Local adverse effects are based on the British National Formulary [BNF 59, 2010] and a drug reference database [Sweetman, 2009].
• Serious adverse effects are rare, and this is reflected in the available safety data. For example, the Summary of Product Characteristics for Betnovate^® (betamethasone valerate) states that both features of Cushing's syndrome and skin disorders (such as thinning, striae, and dilatation) are 'very rare', meaning they affect less than one in 10,000 people (based on case reports rather than controlled trials) [ABPI Medicines Compendium, 2007].

• To minimize the adverse effects of topical corticosteroids:
• Prescribe the least potent formulation which is fully effective (advise the person to apply it thinly to affected areas, no more than twice daily).
• Consider prescribing an appropriate quantity of an emollient for use alongside the topical corticosteroid (for moisturizing purposes).
• Avoid prescribing potent corticosteroids for use on the face.
• Unless under specialist supervision, the use of potent (such as betamethasone valerate 0.1%) and very potent (such as clobetasol propionate 0.1%) topical corticosteroids, should be limited to:
• No more than twice a day for up to 2 weeks, and
• No more than 50 g each week.
• For more information, see the section on Availablity potency and choice in the CKS topic on Psoriasis.
• Avoid using occlusive dressings with topical corticosteroids (especially on large areas of the body).
• If a topical corticosteroid is needed for maintenance therapy, consider incorporating regular periods when they are withdrawn (for as long as possible) and emollients are used on their own.
• If the person is using large amounts of topical corticosteroid regularly, monitor them for signs of systemic adverse effects (such as adrenal suppression) and local adverse effects (such as areas of thin skin or striae).
• Monitor the height of children who are using large amounts of topical corticosteroid.

The recommendations for minimizing adverse effects are based on published expert opinion [Coulson, 1996], a manufacturer's Summary of Product Characteristics [ABPI Medicines Compendium, 2007], the British National Formulary [BNF 59, 2010], and a drug reference database [Sweetman, 2009].

• Topical corticosteroids should not be applied with an occlusive dressing to large areas of the body, as there is a high risk of systemic absorption and adverse effects [Sweetman, 2009].
• Occlusive dressings substantially increase the systemic absorption of topical corticosteroids [ABPI Medicines Compendium, 2007].

• Explain about the potency of the topical steroid that has been prescribed, and if possible provide a written treatment plan, outlining:
• How much to apply — explain finger-tip units (FTUs), and advise the person to apply the topical corticosteroid thinly to the affected area. If the person finds it difficult to understand FTUs, explain that they should ensure that the skin is slightly shiny after the cream is applied.
• How long to apply— advise the person not to use topical corticosteroids for longer than prescribed.
• How often to apply — once daily (or twice daily if absolutely necessary).
• Where to apply — topical corticosteroids should not be applied to the face and other sensitive areas, except when advised.
• How to apply — topical corticosteroids should not be mixed with other creams, except when advised. Advise the person to:
• Use an emollient first, then wait at least 30 minutes before applying the topical corticosteroid (only after the emollient has been fully absorbed).
• Avoid vigorously rubbing the topical corticosteroid into the skin. The corticosteroid should be applied gently in the direction of the hair growth to prevent occlusion folliculitis.
• Reassure the person that, when used correctly, topical corticosteroids rarely cause serious adverse effects. However, advise that they should seek help if they notice any adverse effects (such as skin thinning, stretch marks, or acne).
• Advise the person to carry a steroid treatment card if they are receiving long-term treatment (several weeks) with a potent or very potent topical corticosteroid.

These recommendations are based on published expert opinion [Coulson, 1996; MeReC, 1999] and the British National Formulary [BNF 59, 2010].

• The recommendation to explain about the potency of the prescribed topical corticosteroid and provide a skin treatment plan is based on published opinion, and what CKS considers to be good practice.
• A questionnaire-based study was conducted to determine the level of use, and knowledge, of commonly-prescribed topical corticosteroids among parents or carers of 100 children attending paediatric outpatient clinics [Beattie and Lewis-Jones, 2003].
• 44% of parents/carers graded hydrocortisone 1% as potent.
• 42% did not grade betamethasone valerate 0.1% as potent.
• 29% graded clobetasol butyrate 0.05% as potent, and 12% graded it as weak.
• Poor adherence is a major cause of treatment failure in atopic dermatitis. The reasons for this include fear of adverse effects, failure to renew prescriptions on time, and lack of time. Most important however, is lack of knowledge about the treatment [Beattie and Lewis-Jones, 2003].
• The recommendation to issue a steroid treatment card if the person is receiving long-term treatment (several weeks) with a potent or very potent topical corticosteroid, is based on what CKS considers to be good practice.
• A guideline published by the Medicines and Healthcare products Regulatory Agency (MHRA) advises that high-risk people should be provided with a steroid card, at the discretion of the prescriber or pharmacist [CHM, 2006].
• Most topical corticosteroids may, under certain circumstances, be absorbed in sufficient amounts to cause systemic adverse effects [Sweetman, 2009].