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Am Fam Physician. 2021;103(6):337-343

Related letter to the Editor: Reevaluating the Measurement of Potency of Topical Corticosteroids

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.

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.510 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.2629 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

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.

High-potency steroids (groups I and II)
Alopecia areata
Atopic dermatitis (resistant)
Bullous pemphigoid
Discoid lupus
Dyshidrotic eczema
Hyperkeratotic eczema
Labial adhesion
Lichen planus
Lichen sclerosus (skin)
Lichen simplex chronicus
Nummular eczema
Poison ivy (severe)
Medium-potency steroids (groups III, IV, and V)
Anal inflammation (severe)
Asteatotic eczema
Atopic dermatitis
Dermatitis (severe)
Infantile acropustulosis
Intertrigo (severe, short term)
Lichen sclerosus (vulva)
Nummular eczema
Scabies (after scabicide)
Seborrheic dermatitis
Stasis dermatitis
Low-potency steroids (groups VI and VII)
Dermatitis (diaper)
Dermatitis (eyelids)
Dermatitis (face)
Perianal inflammation

Despite widespread use of topical corticosteroids, high-quality research demonstrating their effectiveness exists for a relatively small number of diagnoses. Multiple systematic reviews support the use of medium- and high-potency topical corticosteroids for the treatment of atopic dermatitis, and intermittent use to prevent a recurrence.3 A Cochrane review found evidence to support the use of topical corticosteroids for the treatment of psoriasis, with super-high-potency corticosteroids being the most effective.4

A limited number of double-blind, randomized controlled trials also support topical corticosteroid use for the treatment of lichen sclerosus,5 alopecia areata,6 vitiligo,7 bullous pemphigoid,8 phimosis,9 and aphthous ulcers.10 Lower-level evidence supports topical corticosteroid use for other conditions, including melasma,11 infantile acropustulosis,12 and prepubertal labial adhesions.13


The strength of a topical corticosteroid is a factor of the agent and concentration. Certain compounds are inherently more potent than others, and potency increases as the concentration of corticosteroid increases.

Topical corticosteroids are grouped into seven classes based on their performance on the vasoconstriction assay, which tests the ability of the corticosteroid to blanch skin. Many can fall into multiple classes based on their concentration. Evidence from small, nonrandomized trials supports the correlation between strength that is measured by the vasoconstriction assay and clinical effectiveness or risk of harm.14 The effectiveness of the corticosteroid may differ depending on the thickness of application, the condition being treated, duration of treatment, and if the medication is a brand name vs. generic formulation.15,16

Although it is not practical to memorize an exhaustive list of corticosteroids, clinicians should be well-acquainted with at least one in each of the low-, medium-, high-, and super-high-potency classes (Table 21,1719). This is sufficient to treat most corticosteroid-responsive skin conditions that present in primary care. Low-potency corticosteroids are useful in children or for mild, widespread disease, or on thin skin areas such as the face and groin. Medium- to high-potency corticosteroids are used for most areas on the body, such as the trunk and extremities. Super-high-potency corticosteroids are useful for severe disease and in areas of thick skin such as the palms, soles, or psoriatic lesions. Except in rare circumstances and for short durations, super-high-potency corticosteroids should not be used in children, under occlusion, or on the face, groin, or skinfolds.

Class (potency)AgentFormulationsMaximum duration*
I (super high)Betamethasone dipropionate augmented 0.05%Ointment, lotion, gel3 weeks
Clobetasol propionate 0.05%Ointment, cream, lotion, gel, foam, solution, shampoo, spray
Fluocinonide 0.1%Cream
Flurandrenolide 4 mcg per cm2 Tape
Halobetasol propionate 0.05%Ointment, cream
II (high)Amcinonide 0.1%Ointment, cream12 weeks
Betamethasone dipropionate 0.05%Ointment
Betamethasone dipropionate augmented 0.05%Cream
Desoximetasone 0.25%Ointment, cream
Desoximetasone 0.05%Gel
Diflorasone diacetate 0.05%Ointment
Fluocinonide 0.05%Ointment, cream, gel, solution
Halcinonide 0.1%Ointment, cream, solution
III, IV, V (medium)Amcinonide 0.1%Lotion12 weeks
Betamethasone dipropionate 0.05%Cream, lotion
Betamethasone valerate 0.12%Foam
Betamethasone valerate 0.1%Ointment, cream, lotion
Diflorasone diacetate 0.05%Cream
Fluocinolone acetonide 0.025%Ointment, cream
Flurandrenolide 0.05%Ointment, cream, lotion
Fluticasone propionate 0.05%Cream, lotion
Fluticasone propionate 0.005%Ointment
Hydrocortisone butyrate 0.1%Ointment, cream, lotion, solution
Hydrocortisone valerate 0.2%Ointment, cream
Mometasone furoate 0.1%Ointment, cream, lotion, solution
Triamcinolone acetonide 0.5%Ointment, cream
Triamcinolone acetonide 0.1%Ointment, cream, lotion
Triamcinolone acetonide 0.147 mg per gSpray
VI, VII (low)Alclometasone dipropionate 0.05%Ointment, creamNo specified limit
Desonide 0.05%Ointment, cream, lotion, gel, foam
Fluocinolone acetonide 0.01%Cream, solution, oil
Hydrocortisone 1%Ointment, cream, lotion, spray
Hydrocortisone 2.5%Ointment, cream, lotion, solution
Triamcinolone acetonide 0.025%Ointment, cream, lotion

Adverse Effects

Topical corticosteroids may cause cutaneous and systemic adverse effects (Table 320). A larger area of application and higher potency of corticosteroid increases the risk of adverse effects. The use of lower-potency corticosteroids and reduction in application frequency can significantly decrease the risk of adverse effects. Thin skin (e.g., the face, intertriginous areas) and the skin of children are more susceptible to adverse effects.17

Cutaneous effects
Atrophic changes
Easy bruising
Increased fragility
Stellate pseudoscars
Steroid atrophy
Aggravation of cutaneous infection
Granuloma gluteale infantum
Masked infection (tinea incognito)
Secondary infections
Contact dermatitis
Delayed wound healing
Hypertrichosis (hirsutism)
Perioral dermatitis
Reactivation of Kaposi sarcoma
Rebound flare-up
Steroid-induced acne
Steroid-induced rosacea
Ocular changes
Ocular hypertension
Systemic effects
Cushing syndrome
Hypothalamic-pituitary-adrenal suppression
Aseptic necrosis of the femoral head
Decreased growth rate
Peripheral edema

The most common adverse effects of topical corticosteroids include atrophy, striae, rosacea, perioral dermatitis, acneiform eruption, and purpura.20 Other cutaneous adverse effects include folliculitis, periocular dermatitis, delayed wound healing, gluteal granulomas, telangiectasias and erythema, hypopigmentation, hypertrichosis, masking or aggravation of dermatophyte infection (tinea incognito), secondary infection, and contact dermatitis.17 Mucocutaneous infections are also common with topical corticosteroid use.20 The inflammatory suppression from topical corticosteroids can contribute to the prolongation, progression, and atypical presentation of cutaneous infections. Contact sensitization to topical corticosteroids can also occur but is rare. Differentiation from hypersensitivity to other components of the topical treatment is important if contact sensitization is suspected.

Systemic adverse effects that have been reported with topical corticosteroid use include cataracts, glaucoma, adrenal suppression, decreased growth rate, hypertension, hyperglycemia, and Cushing syndrome.20 Adverse effects are rare with low-potency topical corticosteroids.17 Evidence suggests that the risk of systemic adverse effects in adults is low if doses do not exceed 50 g per week, even with super-high-potency formulations.21 Children are also more susceptible to systemic adverse effects because of their increased ratio of body surface area to weight.

Patients undergoing long-term treatment with topical corticosteroids should be monitored for the development of adverse effects, particularly when used in thin skin areas or with susceptible populations such as children or older people.20

No association has been noted between the maternal use of topical corticosteroids and adverse pregnancy outcomes, including mode of delivery, congenital abnormality, preterm delivery, fetal death, or a low Apgar score.22 Topical corticosteroid use has not been associated with adverse effects in patients who are lactating.20

There is no evidence that topical corticosteroids lose effectiveness over time (tachyphylaxis).23 However, corticosteroid withdrawal (i.e., corticosteroid addiction) can occur upon cessation after prolonged use on the face and genitals, causing erythema, scaling, stinging, burning, papules, pustules, and edema.24


Topical corticosteroids come in several formulations, each with advantages and disadvantages. The most common formulations include ointments, creams, lotions, gels, foams, and solutions.18

Ointments are petroleum-based. They are thick and lubricating and are useful for dry or hyperkeratotic lesions on smooth, nonhairy skin. Ointments are occlusive and leave a residue on the skin after application. They generally have fewer added compounds and are therefore less prone to provoke allergic reactions.25 Ointments can be less irritating to thin skin and should be avoided on intertriginous (e.g., groin, gluteal cleft, axilla) or hairy areas because they can promote maceration and folliculitis.

Creams and lotions are mixtures of water and oil. Lotions have higher water content than creams and are pourable. Lotions and creams vanish into the skin when applied. Creams are less occlusive than ointments, and lotions are less occlusive than creams. Lotions are easier to apply to hair-bearing areas. Lotions and creams commonly contain added compounds such as alcohols, which may cause irritation or allergic reactions.25 Lotions and creams can have a drying effect, which may be useful for acute exudative inflammation.

Gels are aqueous, dry rapidly, and leave little residue. Gels often sting when applied to inflamed, fissured, or eroded skin and have a drying effect. They are useful for hairy areas or when the patient wishes to avoid the greasy feeling of ointments, creams, and lotions.

Foams are dispensed from specialized containers, spread easily, and are especially useful for hair-bearing areas such as the scalp or beard. They are well-tolerated by patients but can be expensive.

Solutions and oils are liquids containing the desired corticosteroid. They spread easily and are useful for areas with dense hair such as the scalp or beard. They are not occlusive, and oils may leave a residue. Certain solutions may be delivered via a spray. Solutions often contain alcohols and may sting or burn when applied to inflamed, fissured, or eroded skin. Solutions and oils are less allergenic than lotions.25 Similar to solutions and oils, shampoos effectively deliver corticosteroids to hairy areas such as the scalp.

The choice of formulation affects the absorption of the corticosteroid; however, the differences in absorption between formulations do not likely result in a clinically meaningful change in effectiveness or risk of harm.26 Although ointments have classically been considered more potent than creams or lotions, evidence from multiple small, nonblinded, randomized trials suggests that creams, ointments, and lotions have similar levels of effectiveness.27,28 Patients typically prefer creams and lotions over ointments because they are less greasy and vanish more easily. Foams may be more preferred for all applications, particularly in areas with thick hair such as the scalp.29 The choice of formulation should be based on characteristics of the lesion, cost, and patient preference over the potential differences in strength.2629

Duration and Frequency of Treatment

The duration of treatment depends on the strength of the corticosteroid and the condition being treated. In general, super-high-potency topical corticosteroids should be used for no more than three weeks at a time. High- and medium-potency corticosteroids should be used for no more than 12 weeks at a time. For treatments of longer duration, a potent corticosteroid may be used intermittently or transitioned to a milder corticosteroid for ongoing control. Lesions on the face, groin, and skinfolds may be treated in one- to two-week intervals. Therapy may be discontinued when the lesions resolve.17

Topical corticosteroids are usually applied once or twice per day. More frequent administration does not typically improve results and decreases patient adherence.30 The application frequency can be adjusted according to effect and patient tolerance. Topical corticosteroid penetration is enhanced by using an occlusive method such as a plastic wrap, bandages, or gloves.18,31 Penetration improves when the skin is moist; however, it is unclear whether corticosteroid application after a bath or shower produces superior results compared with application at other times.32

Prescribing and Application

A prescription for topical corticosteroids should include the medication name, concentration, formulation, directions for application, and amount. The choice of which agent, concentration, and formulation to use depends on the condition being treated, the location on the body, characteristics of the lesion, and patient factors such as age. The amount prescribed depends on the size of the area being treated, frequency, skin location, and duration of treatment.

A standard unit used for topical corticosteroid application is the fingertip unit. One fingertip unit is the amount of medication dispensed from a standard 5-mm nozzle over a distance from the tip of the index finger to the crease of the distal interphalangeal joint. This represents approximately 0.5 g of medication and should cover approximately 2% of the body surface area on an adult.33 The area of an adult patient's palm represents approximately 1% of body surface area or one-half of a fingertip unit. For example, 30 g should be sufficient for twice daily application to an area the size of two adult palms for 30 days (Table 4).34

Body areaFingertip units required for one applicationWeight required for twice per day dosing for 30 days
Face and neck2.575 g
Front of trunk7210 g
Back of trunk7210 g
One arm390 g
One hand (front and back)130 g
One leg6180 g
One foot260 g

Proper patient application is critical for the effectiveness of topical corticosteroids. 15,35 Patients should be taught how to apply medication using the fingertip unit method.33,34 This helps ensure that they do not apply the medication too thinly (which can result in an insufficient effect) or too thickly (which increases the risk of adverse effects).36 If a patient reports the corticosteroid is less effective than expected, clinicians should assess for difficulty with compliance and barriers to adherence. The size of an adult hand can approximate the area of application using the fingertip unit method, or the clinician may consider the approximate dose adjustment listed in Table 5.37

Age groupDose adjustment
InfantsOne-fifth of the adult dose
ChildrenTwo-fifths of the adult dose
AdolescentsTwo-thirds of the adult dose

This article updates a previous article on this topic by Ference and Last.2

Data Sources: A search of PubMed, the Cochrane database, Essential Evidence Plus, and Mayo Clinic Library services was conducted using key terms including but not limited to corticosteroid, dermatology, topical, potency, ointment, cream, foam, fingertip unit, penetration, occlusion, vasomotor, side effects, pediatric, pregnancy, breastfeeding, treatment, and other keywords identifying inflammatory skin diseases. The references from the previous American Family Physician article on this topic were reviewed and included when appropriate. Search dates: August 2020, September 2020, and February 2021.

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