Topical Corticosteroids: Choice and Application
Am Fam Physician. 2021 Mar 15;103(6):337-343.
Author disclosure: No relevant financial affiliations.
Topical corticosteroids are an essential tool for treating inflammatory skin conditions such as psoriasis and atopic dermatitis. Topical corticosteroids are classified by strength and the risk of adverse effects such as atrophy, striae, rosacea, telangiectasias, purpura, and other cutaneous and systemic reactions. The risk of adverse effects increases with prolonged use, a large area of application, higher potency, occlusion, and application to areas of thinner skin such as the face and genitals. When prescribing topical corticosteroids for use in children, lower potencies and shorter durations should be used. Topical corticosteroids can work safely and effectively in patients who are pregnant or lactating. They are available in formulations such as ointments, creams, lotions, gels, foams, oils, solutions, and shampoos. The quantity of corticosteroid prescribed depends on the duration of treatment, the frequency of application, the skin location, and the total surface area treated. Correct patient application is critical to successful use. Patients may be taught application using the fingertip unit method. One fingertip unit is the amount of medication dispensed from the tip of the index finger to the crease of the distal interphalangeal joint and covers approximately 2% body surface area on an adult. Topical corticosteroids are applied once or twice per day for up to three weeks for super-high-potency corticosteroids or up to 12 weeks for high- or medium-potency corticosteroids. There is no specified time limit for low-potency topical corticosteroid use.
Effective treatment of dermatologic disorders depends on an accurate diagnosis based on history, physical examination, and appropriate diagnostic tests such as biopsy or skin scraping. Typical characteristics of skin diseases amenable to treatment with topical corticosteroids include inflammation, hyperproliferation, and immunologic etiology.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
Use topical corticosteroids to treat psoriasis and atopic dermatitis.3,4 | A | Multiple randomized controlled trials and meta-analyses show consistent improvement with corticosteroid use |
Use topical corticosteroids to treat inflammatory skin diseases, including lichen sclerosus, alopecia areata, vitiligo, bullous pemphigoid, phimosis, and aphthous ulcers.5–10 | B | Expert opinion, consensus guidelines, and inconsistent results from multiple small, well-controlled studies |
Base the choice of a corticosteroid formulation on characteristics of the lesion, cost, and patient preference. Potential differences in strength between formulations should not be the main factor in choice.26–29 | C | Expert opinion and disease-oriented evidence |
Teach patients how to apply topical corticosteroids using the fingertip unit method.33,34 | C | Expert opinion and consensus guidelines |
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
Use topical corticosteroids to treat psoriasis and atopic dermatitis.3,4 | A | Multiple randomized controlled trials and meta-analyses show consistent improvement with corticosteroid use |
Use topical corticosteroids to treat inflammatory skin diseases, including lichen sclerosus, alopecia areata, vitiligo, bullous pemphigoid, phimosis, and aphthous ulcers.5–10 | B | Expert opinion, consensus guidelines, and inconsistent results from multiple small, well-controlled studies |
Base the choice of a corticosteroid formulation on characteristics of the lesion, cost, and patient preference. Potential differences in strength between formulations should not be the main factor in choice.26–29 | C | Expert opinion and disease-oriented evidence |
Teach patients how to apply topical corticosteroids using the fingertip unit method.33,34 | C | Expert opinion and consensus guidelines |
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
Topical corticosteroids are approved by the U.S. Food and Drug Administration for the relief of the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.1 Table 1 lists skin conditions that respond to treatment with topical corticosteroids.2 This article discusses the use of topical corticosteroids on nonmucosal surfaces.
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