Topical corticosteroid preparations are used in the treatment of inflammatory skin conditions other than those due to an infection. They are not curative, and should be backed up with other measures, in particular irritant avoidance and regular emollients (see references).

• They should not be used indiscriminately for pruritus, urticaria, or in undiagnosed rashes.
• They are contra-indicated in rosacea.
• And care should be taken, with regular review, when treating delicate areas of skin (face, groin, axillae or breast) or an eruption where the diagnosis is unclear.

In general, ointment preparations are preferable for dry, scaly conditions; creams for moist ‘steamy’ areas (eg, axillae and groin) and gels/ lotions for the scalp.

Potency

• Choice of steroid strength will depend on the nature of the condition being treated, the age of the patient and the site of disease, the aim being to use the weakest preparation that will suppress the inflammation.
• Take particular care when treating the face and flexures of children (especially under wet wrap dressings).
• It is reasonable to supply 2 strengths for patients with chronic conditions, one to be used for maintenance and a stronger one, for short-term use, during flare-ups.

Potent steroids

In general, potent steroid preparations should only be used on ‘tough’ areas of skin (trunk and limbs). Delicate areas such as face, groin and axillae should be treated with mildly potent steroid preparations.

• Potent steroids should only be used in psoriasis (other than on the scalp) under supervision due to the risk of provoking a severe pustular flare.
• Potent steroids can be used in recalcitrant conditions such as palmoplantar pustulosis, lichen simplex and nodular prurigo, provided that patients are reviewed regularly to ensure treatment is appropriate.
• Prolonged use of potent steroids will lead to skin atrophy with easy bruising and striae formation and, rarely, might even suppress the pituitary-adrenal axis.
• Facial use may cause a rosacea-like papular eruption (perioral dermatitis).

Very potent steroids

• The very potent steroids, clobetasol propionate (Dermovate®, ClobaDerm®) and mometasone (Elocon) should be used with caution, for brief periods only (preferably no longer than 2 weeks) and reviewed by the prescriber at least monthly.
• Very potent steroids should not usually be on repeat prescription, other than in special circumstances, eg, vulval lichen sclerosus, see British Association of Dermatology guidance and patient information leaflet.

Compound preparations

• Compound preparations, which contain antimicrobial agents, are useful where there is overt secondary infection. Their use otherwise is debatable, although they are often used where there may be a microbial component present such as in flexures.
• Those containing fusidic acid should only be used for short periods of time (up to 10 days) to reduce the likelihood of developing bacterial resistance and provoking MRSA colonisation.
• They should never be on repeat prescription.

Application

• Apply topical steroids once daily in general.
• When applying along with an emollient, it does not matter which agent is applied first; allow one to dry in before applying the other.
• As an eruption settles, taper application gradually to every 2nd day before stopping, usually after 10 to 14 days.

Fingertip units can be helpful when determining prescription quantities. One fingertip unit (approximately 500mg), which covers the distal phalanx of the forefinger when squeezed out of the tube, is sufficient to cover the area of both hands, approximately 2% of skin area in an adult.