Topical Corticosteroids

Introduction to Topical Corticosteroids

Topical corticosteroids are classified into different potency classes, with medium potency corticosteroids including clocortolone pivalate 0.1%, clobetasone butyrate 0.05%, betamethasone valerate 0.025%, and fluocinolone acetonide 0.025% 1, 2
Hydrocortisone butyrate 0.1% is also considered a medium potency corticosteroid 3

Maintenance therapy in atopic dermatitis can be achieved with twice weekly application of medium potency corticosteroids 3
The American Academy of Dermatology recommends using medium potency corticosteroids with caution on thin skin areas, such as the face and intertriginous areas, due to the risk of local side effects like skin atrophy, telangiectasia, and striae 1
Tachyphylaxis, or decreased effectiveness with continued use, may occur with long-term application of medium potency corticosteroids, and gradual reduction in usage is recommended following clinical response 1
The efficacy of topical corticosteroids varies by potency class, with the following efficacy rates:
| Potency Class | Efficacy Rate | | --- | --- | | Class 1 (Superpotent) | 58%-92% | | Class 2 (Potent) | 68%-74% | | Classes 3-4 (Upper-midstrength and Midstrength) | 68%-72% | | Classes 5-7 (Lower-midstrength and Low potency) | 41%-83% | 1

Pediatric patients should use the lowest effective potency for the shortest possible duration 1
Elderly patients are at higher risk of skin atrophy and require close monitoring 1, 4
Pregnant and breastfeeding women can use low-potency corticosteroids, which are generally safe 4, 5, 6

For facial involvement, the American Academy of Dermatology recommends considering tacrolimus 0.1% ointment instead of corticosteroids 7
For mild cases with minimal scaling, low-potency corticosteroid (hydrocortisone 1-2.5%) twice daily for 2-4 weeks, plus daily emollient and sunscreen, is recommended 8, 4
For moderate cases with noticeable scaling, betamethasone (medium-potency) twice daily for 2-4 weeks, with reduction to weekend-only application after improvement, and close monitoring for side effects, especially on facial skin, is suggested 8
For persistent cases or concerns about steroid side effects, consideration of tacrolimus 0.03% ointment or calcipotriol 0.005% cream, applied twice daily for 8 weeks, may be beneficial 8

Combination therapy with vitamin D analogs (calcipotriol) can increase efficacy and reduce side effects 9, 5
Using topical corticosteroids in combination with emollients may allow for reduced frequency of application 9
Daily use of mild, soap-free cleansers, regular application of emollients, consistent use of sunscreen (SPF 15+), and avoidance of irritants that may exacerbate the condition are recommended for prevention and maintenance 8, 4

For severe or widespread disease, consider systemic therapy if inadequate response after 2-4 weeks, and avoid systemic corticosteroids as they may precipitate erythrodermic psoriasis, generalized pustular psoriasis, or unstable psoriasis upon withdrawal 10
Oral prednisone may be initiated at 1 mg/kg/day with tapering over at least 4 weeks for Grade 3 erythrodermic psoriasis (covering >30% BSA with moderate/severe symptoms) 11
For moderate-to-severe psoriasis, cyclosporine (3-5 mg/kg/day), methotrexate, biologic agents (such as TNF inhibitors, IL-17 inhibitors, IL-23 inhibitors, and ustekinumab), and acitretin are recommended instead of oral steroids 9