Am Fam Physician. 2021;103(6):337-343
Related letter: 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.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 |
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 Melasma Nummular eczema Poison ivy (severe) Psoriasis Vitiligo | 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) Intertrigo Perianal inflammation Phimosis |
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
Potency
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 21,17–19 ). 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) | Agent | Formulations | Maximum duration* |
|---|---|---|---|
| I (super high) | Betamethasone dipropionate augmented 0.05% | Ointment, lotion, gel | 3 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, cream | 12 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% | Lotion | 12 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 g | Spray | ||
| VI, VII (low) | Alclometasone dipropionate 0.05% | Ointment, cream | No 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
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