Topical Corticosteroids for Atopic Dermatitis

Introduction to Treatment

The American Academy of Dermatology strongly recommends topical corticosteroids as first-line treatment for adults with atopic dermatitis, with selection based on potency class (I-VII) and using the least potent preparation required to control symptoms 1, 2

Topical corticosteroids are grouped into 7 classes based on potency, with Class I being very high potency (e.g., clobetasol propionate 0.05%) and Class VII being low potency (e.g., hydrocortisone 1%) 3
The American Academy of Dermatology recommends considering anatomical site when selecting potency, with lower potency agents for face, neck, genitals, and body folds, and medium to high potency for trunk and extremities 3

Treatment should not be applied more than twice daily, with most studies involving twice daily application, though once daily may be sufficient for potent topical corticosteroids 2, 3, 4
For maintenance therapy between flares, intermittent use of medium potency topical corticosteroids (twice weekly) is strongly recommended to reduce disease flares and relapse, with patients treated with fluticasone propionate 0.05% cream being 7.0 times less likely to have an AD relapse compared to vehicle (95% CI: 3.0-16.7; P < .001) 1, 3

The main risk with potent topical corticosteroids is suppression of the pituitary-adrenal axis, with other potential side effects including skin atrophy, telangiectasias, and hypopigmentation, especially with prolonged use of higher potency steroids 2, 5
The British Medical Journal recommends using the least potent preparation required to keep eczema under control, and when possible, corticosteroids should be stopped for short periods 2, 4

For patients concerned about topical corticosteroid side effects, the American Academy of Dermatology strongly recommends considering tacrolimus 0.03% or 0.1% ointment, pimecrolimus 1% cream, crisaborole ointment, and ruxolitinib cream for mild-to-moderate disease 1, 3
Emollients should be used in conjunction with topical corticosteroids and are most effective when applied after bathing, with antihistamines being useful as short-term adjuvants during relapses with severe pruritus 2, 4, 5

Applying a topical corticosteroid once or twice daily is the standard approach for controlling active inflammation in atopic dermatitis flares【6】【7】【8】.
The intensive regimen should be continued for 1–4 weeks or until lesions show significant improvement【7】【8】.

After disease control, twice‑weekly application of a low‑ to medium‑potency corticosteroid to previously affected areas is recommended for proactive maintenance【6】.
Proactive twice‑weekly therapy can be continued for up to 16 weeks and reduces the risk of subsequent flares by approximately seven‑fold compared with emollient‑only care (95 % CI 3.0–16.7; P < 0.001)【6】.
Applying a medium‑strength corticosteroid 2–3 times per week to normal‑appearing skin at sites prone to flares maintains better overall disease control【7】【8】.

Facial, neck, genital, and skin‑fold areas: use low‑potency corticosteroids cautiously; once‑daily dosing or alternative agents are advisable【6】.
Trunk and extremities: medium‑ to high‑potency corticosteroids may be applied once or twice daily during acute flares【6】.
Infants and young children: select less potent formulations to minimize the risk of systemic absorption and adrenal suppression【6】.

Stopping treatment prematurely (before achieving clear improvement) leads to rapid relapse【7】【8】.
Omitting proactive twice‑weekly maintenance markedly increases relapse rates【6】.
Using high‑potency steroids on thin skin (e.g., face or folds) can cause atrophy, telangiectasias, and striae; low‑potency agents are preferred【6】.

Pituitary‑adrenal axis suppression is a notable risk when potent corticosteroids are used over large body‑surface areas in children【6】.