Topical steroids are a form of steroids, which are used for local application. They are neither ingested nor injected into the body.
They are available in various forms, like for example:
- Steroid creams and ointments, which are used for application on the skin
- Nasal sprays used for conditions such as allergic rhinitis, also called Hay fever and
- Eye drops used to treat inflammatory eye conditions.
They come with various names and potency. They can be mildly potent for use on sensitive areas of the body like the face or moderately potent or strong and ultra-potent for use in skin conditions like psoriasis.
Some are safe for use during pregnancy and breast feeding, while some are not. Some are available over the counter (OTC) while some are available under prescription only.
What are topical steroids?
Topical steroids are also called topical corticosteroids. In order to understand them, first let us understand what steroids are.
Steroids are hormones naturally manufactured in the body. They can be grouped into two types:
1. Corticosteroids, which are manufactured in the adrenal cortex of the adrenal or the suprarenal glands, hence the name “cortico”. These are the steroids that are present in steroid medications.
2. Sex steroids, which are made in the testes in males (testosterone) and the ovaries in females (estrogen and progesterone). They are also made by the adrenal glands (also called the suprarenal glands), which sit atop the kidneys.
Anabolic steroids are synthetic and similar in structure to the male sex hormone, testosterone. They work differently and are used by the athletes and bodybuilders to build muscle.
Corticosteroids are manufactured by man and used in making steroid medicines. They are similar in structure to the steroids manufactured by the cortex of the adrenal gland. One of such medicines are topical steroids.
Topical medications are those, which are not used systemically — that is, they are not taken orally or by injections. They are used for external application on the skin or sprayed into the nose or drops for use in the eyes.
Steroids have a potent anti-inflammatory property because of their action of narrowing the blood vessels. It is this property of theirs that makes them useful to treat inflammatory conditions.
They are notorious among the population for their side effects, which is true, but they have their life saving uses. Topical steroids, however, are quite safe if used correctly.
Uses of topical steroids
Topical steroids are used to treat inflammatory conditions of the skin; the eyes and the nose. These include
- Skin rash
- Contact dermatitis due to skin contact with allergens such as poison ivy
- Hay fever also called allergic rhinitis
- Allergic reactions
- Inflammatory conditions of the eyes
- Local inflammation in the nose
- If you consider nasal sprays as a topical application, then steroid nasal sprays help to reduce the inflammation in the nasal passages
Forms of topical steroids
They are used locally and are available as ointments, creams, gels, lotions, solutions, nasal sprays, eye drops and suppositories.
Creams are the most popular, though of a weaker potency, because they are water soluble and easy to wash off.
Each of these is again available in varying potencies, from mildly potent to highly potent.
Which form of topical steroid to use and where?
- Creams are usually best to treat moist areas of skin.
- Ointments are advised to treat areas of skin which are dry or thickened.
- Lotions are used to treat hairy areas such as the scalp.
- Nasal sprays are used to treat allergic rhinitis (Hay fever). Examples include beclometasone nasal spray and fluticasone nasal spray.
What do topical steroids do and how?
- Since topical steroids are typically used to treat allergic reactions, listed above, it is necessary that they suppress the immune system at the local level. This is because allergy is an abnormal reaction of the body’s immune system to a substance (allergen).
- Secondly, because of their anti-inflammatory properties, they clear up the redness and the swelling associated with these allergic reactions.
- Their application also helps to reduce collagen of the skin.
- Thirdly, they narrow down the blood vessels and the capillaries, which are enlarged due to the inflammation. This happens because of their vasoconstrictor properties.
Initially while starting treatment with these topicals, you may experience a burning sensation, but this mostly clears up over time.
Topical steroids are also available in combination with topical antibiotics. Example includes Pimafucort Cream (Hydrocortisone/Neomycin Sulfate). Such combinations are used when the inflammation is super added with bacterial infection.
They are also found combined with antifungal agents to treat a fungal infection that may be present. Example includes clotrimazole/betamethasone
List of topical corticosteroids
The list of the generic and brand names of topical corticosteroids and their potencies is long and they are well listed at drugs.com
Types of topical steroids, their potency and areas to use
Topical steroids can be classified as:
- Weakly potent
- Moderately potent
- Highly potent
Weak topical steroids for face
Weak topical steroids are used for dermatitis in the areas of the body where the skin is thin and sensitive. Such areas include the face and the eyelids, the armpits, the crease between the buttocks, the groin, the perianal area, the diaper area and the folds of the breasts. They are also used for pain and swelling due to sunburn and heat rash
Example includes 0.5% to 1% hydrocortisone.
Moderately potency steroids for eczema
Moderately potency steroids are used for vulvovaginal irritation, eczema, atopic dermatitis, and scabies after its treatment.
Strong topical steroids for psoriasis
Strong topical steroids are used in psoriasis, contact dermatitis due to poison ivy, lichen planus (an autoimmune disorder) and in alopecia areata (a type of hair loss) for hair growth. Example: Mometasone and clobetasol or halobetasol 0.05% in an ointment base.
Netdoctor.co.uk has a good chart showing the potency and examples of topical steroids.
OTC and prescription topical asteroids
Mild topical steroids such as hydrocortisone acetate 0.5% and 1% are available over the counter. Similarly, you can also buy nasal sprays such as beclometasone nasal spray and fluticasone nasal spray to treat allergic rhinitis.
Moderate and strong topical steroids are available by prescription only.
How to use and stop application of topical steroids?
Application criteria depends on what the condition is and how mild or severe it is.
Topical steroids are rubbed gently on the affected area once or twice a day. At times, for chronic cases such as eczema or psoriasis, you may need long term application.
In such cases, you should apply them for one week followed by a week of no application. This is done to prevent tachyphylaxis, which means rapid decrease in the response to the medicine after its use.
If you have been using strong topical steroids over a prolonged period, as is required in psoriasis, you should not stop using them abruptly. This will cause the condition to recur immediately. You should taper the application down slowly.
Short term application can be stopped immediately
How much topical steroids to apply?
In topical medicine, there is a term called Finger Tip Unit (FTU). It defines the amount of cream or ointment to be used for one time application in adults.
You squeeze the cream from its tube usually through a 5 mm nozzle onto your index finger, from the end of finger tip to the distal crease nearest to the same fingertip.
This much of the cream or ointment is enough for application on the skin surface twice the area of the flat of your hand with fingers held together
Side effects of long term topical steroid use
When used correctly, topical steroids rarely cause any side effects. Their use over prolonged periods can give rise to certain adverse side effects. They include:
- Secondary bacterial infection
- Secondary fungal infection
- Atrophy of the affected skin
- Fragility of the affected skin part
- Folliculitis and pimples
- Loss of skin pigment
- Loss of hair growth at the site of application
- Dilation of the blood capillaries present near the skin surface or the mucosa of the affected part
- Long term use of nasal sprays can cause dryness and irritation of the nose, as well as bleeding through the nose. Your sense of taste and smell may be affected
- Long term use of steroid eye drops can cause increase in ocular pressure, cataracts, and blurred vision.
All low to moderate potency topical steroids should be applied intermittently, as explained above and not for more than three months to avoid side effects.
High potency topical steroids should not be used for more than three weeks.
These restrictions are being advised because long term application or application over a wide area can absorb the steroids into the blood and can cause Cushing’s syndrome or suppression of the adrenal glands.
Choosing the right topical steroid
Conditions where mild topical steroids (such as 1% hydrocortisone cream eg. Cortaid) can be used:
- sunburn pain and swelling
- heat rash
- for application on the face and eyelids
- in areas of the body where the skin is sensitive and thin
Moderate or high-potency topical steroids, such as triamcinolone 0.1% or clobetasol 0.05% can be used to treat
Contact dermatitis due to poison ivy
- Lichen planus
- Vaginal irritation
Are topical steroids safe to use during pregnancy?
According to Medscape:
“The current best evidence suggests that mild/moderate topical corticosteroids are preferred to potent/very potent ones in pregnancy, because of the associated risk of fetal growth restriction with the latter”.
Are topical steroids safe during breast feeding?
Only mild topical steroids used over short term are considered safe during lactation. If you have applied the cream to your breast, you should thoroughly wash the affected part before breast feeding your baby.
Do not use moderate or strong topical steroids when you are lactating.
Use of topical steroids in children
Use of strong topical steroids in children long term can affect the growth of the child. Therefore, only mild local steroids should be used. However, if the condition warrants long term and frequent use of strong topical steroids, then the child’s growth should be monitored periodically. It is best to consult your health provider in such circumstances.