Overview of Topical Steroids

Topical steroids, or topical corticosteroids, are medications that are applied directly to the skin. They are used to relieve skin conditions that cause skin inflammation and irritation. When used as directed by your healthcare provider, topical steroids are a safe and effective way to treat conditions such as eczema, psoriasis, and atopic dermatitis.

Topical steroids can be prescribed or purchased over-the-counter (OTC). They come in a variety of strengths and forms, such as creams or ointments.

This article will explore how topical steroids work, the way they are grouped based on strength, and examples of medications.

What Are Topical Steroids?

Topical steroids are medications that reduce inflammation in your skin.

Inflammation is a sign of an immune response. The treatment is applied to an affected area of skin to help reduce symptoms such as rashes, scaly patches, itching, pain, redness, or swelling.

For example, eczema, also known as atopic dermatitis, is a group of skin conditions that lead to itchy and inflamed skin with a scaly rash. Eczema is common in children. If you experience a flare-up of eczema, you can apply a cream to help you stop scratching the area and allow your skin to heal.

Topical steroids may be used for other skin conditions such as:

• Psoriasis, an autoimmune disorder that causes scaly patches of skin
  
• Seborrheic dermatitis, a skin rash with red patches and greasy yellow scales that typically affects the scalp
• Contact dermatitis, a red rash caused by contact with a substance that irritates the skin or causes an allergic reaction to it

The skin has two main layers: an outer layer called the epidermis and the inner layer called the dermis.

The strength of a topical steroid is determined by a test that measures how much it can cause your blood vessels to constrict in the upper part of the dermis.

As blood vessels constrict, it can reduce swelling and discomfort.

Formulations

Topical steroids are usually applied in a thin layer and massaged into your skin anywhere from one to four times a day.

They can come in different forms including:

• Creams, which are the most commonly prescribed, are a mixture of water and oils and usually contain a preservative. They're especially good for hairy and wet areas and are easily applied without a greasy feel.
• Ointments are made of oils and little to no water and don't usually contain a preservative. They're great for dry, scaly skin or areas with thick skin like the soles of your feet and the palms of your hands.
• Gels are made with water and propylene glycol, a synthetic alcohol. Like creams, they're easy to apply.
• Solutions, foams, and lotions usually contain oil, water, and chemicals and are used on your scalp.

Classification by Strength 

Topical steroids come in a range of strengths and are divided into seven classes based on how strong they are. The strongest steroids are in Class I (class one) and the weakest steroids are in Class VII (class seven).

Class I topical steroids are approximately 600 to 1,000 times stronger than those in Class VII.

Treatment Considerations

The appropriate steroid strength, or potency, depends on a variety of factors.

For example, babies absorb topical steroids much faster than adults, so they may require a low-potency steroid.

Areas of the body where skin touches skin, such as the armpits or under the breasts, or sensitive areas of skin such as the eyelids, also absorb topical steroids quickly and may only need a low-potency formulation.

However, thick, rough skin on the palms of your hands and the soles of your feet usually absorbs topical steroids more slowly than other parts of the body, so those areas typically require a more potent steroid.

Side Effects

The greater the potency of a topical steroid, the greater the risk of side effects. Common side effects of topical steroids include:

• Skin thinning
• Easy bruising
• Enlarged blood vessels (telangiectasia)
• Thickening of hair (hypertrichosis)
• Stretch marks in the armpits or groin
• Burning or stinging where the medication is applied

Topical Steroid Withdrawal

It is possible to overuse topical steroids, which could result in withdrawal symptoms. This can happen if you use mid- to high-strength topical steroids frequently, for a long time, or on sensitive parts of your body like your face or genitals. 

Generally speaking, you should not use low-strength topical steroids for more than three months. High-strength topical steroids should not be used for more than three weeks.

Withdrawal symptoms occur when you stop using topical steroids but may take up to two weeks to appear. They may include:

• Bright red skin that burns or stings
• Swelling
• Sensitivity  
• Bumps on the skin

If you think you are experiencing withdrawal symptoms, talk to your healthcare provider. It's possible to mistake eczema or other skin conditions for topical steroid withdrawal, so it's important to get a proper diagnosis and start an alternative treatment if appropriate.

Your healthcare provider can help you weigh the risks and benefits of using a topical steroid and to find a strength that may be best suited for your skin condition.

How long the drug should be used will also vary based on your condition.

Follow all instructions for using the drug properly and contact your provider if it isn't helping with your symptoms or it leads to more irritation. You may need a change in potency or formulation or you may need to stop using the medication.

Medication Options

There are many medications and formulations within each class of topical steroids.

Topical Steroid Class I

The highest potency topical steroids include:

• Temovate (clobetasol propionate) 0.05% ointment
• Ultravate (halobetasol propionate) 0.05% cream, ointment, or lotion
• Psorcon (diflorasone diacetate) 0.05% ointment
• Diprolene (betamethasone dipropionate) 0.25% ointment or gel

Topical Steroid Class II

These topical steroids are considered highly potent:

• Lidex (fluocinonide) 0.05% cream, gel, ointment, or solution
• Halog (halcinonide) 0.1% cream, ointment, or solution
• Cyclocort (amcinonide) 0.1% ointment
• Topicort (desoximetasone) 0.25% cream or ointment

Topical Steroid Class III

These topical steroids are considered potent:

• Elocon (mometasone furoate) 0.1% ointment
• Cutivate (fluticasone propionate) 0.005% ointment
• Betanate (betamethasone dipropionate) 0.05% cream
• Kenalog (triamcinolone acetonide) 0.5% cream or ointment

Topical Steroid Class IV

These topical steroids are considered moderately potent:

• Synalar (fluocinolone acetonide) 0.025% cream or ointment
• Cordran (flurandrenolide) 0.05% cream, ointment, or lotion
• Triderm (triamcinolone acetonide) 0.1% cream, ointment, or lotion
• Elocon (mometasone furoate) 0.1% cream, lotion, or solution
• Cutivate (fluticasone propionate) 0.05% cream

Topical Steroid Class V

These topical steroids are considered somewhat potent:

• Westcort (hydrocortisone valerate) 0.2% cream or ointment
• Locoid (hydrocortisone butyrate) 0.1% ointment
• Dermatop (prednicarbate) 0.1% cream or ointment
• Pandel (hydrocortisone probutate) 0.1% cream

Topical Steroid Class VI

These topical steroids are considered mild:

• Desonate (desonide) 0.05% gel
• Synalar (fluocinolone acetonide) 0.025% cream, solution, or shampoo
• Locoid (hydrocortisone butyrate) 0.1% cream, lotion, or solution

Topical Steroid Class VII

These topical steroids are considered the least potent:

• Hytone (hydrocortisone) 2.5% cream and lotion
• Hydrocortisone 1% (many over-the-counter brands of creams, ointments, and lotions)
• Anusol-HC (hydrocortisone acetate) 0.5% and 1% creams
  

Summary

Topical steroids are medications applied to the skin to reduce inflammation and irritation.

They come in over-the-counter and prescription options with a range of strengths and formulations. Class VII steroids, which includes OTC hydrocortisone creams, are the mildest, while Class I are the strongest.

Your doctor can help you to decide if a topical steroid makes sense for treating your skin condition and what potency and length of treatment may be most helpful in your case.