From the Guidelines
For a rash resistant to oral prednisone, a high-potency topical steroid like clobetasol propionate 0.05% (Temovate) would be the best option, as it has been shown to be effective in treating various dermatological conditions, including psoriasis and bullous pemphigoid, with a significant benefit in disease control and reduced adverse events compared to oral prednisone 1. When using clobetasol propionate 0.05%, it is recommended to apply a thin layer to the affected area twice daily for up to two weeks, as prolonged use can increase the risk of cutaneous side effects and systemic absorption 1. Other effective high-potency options include:
- Betamethasone dipropionate 0.05% (Diprolene)
- Fluocinonide 0.05% (Lidex) For sensitive areas like the face, groin, or skin folds, consider a medium-potency steroid such as:
- Triamcinolone 0.1%
- Mometasone furoate 0.1% to reduce the risk of skin atrophy. Use occlusion (covering the area with plastic wrap after application) to enhance penetration for particularly stubborn rashes. If the rash remains unresponsive after two weeks, consider adding other treatments like calcineurin inhibitors (tacrolimus or pimecrolimus) or seeking dermatology consultation for alternative diagnoses or treatments. High-potency topical steroids work by providing concentrated anti-inflammatory effects directly at the site of inflammation, which can be more effective than systemic steroids for certain dermatological conditions, with reduced morbidity and mortality attributable to corticosteroid treatment 1.
From the FDA Drug Label
Studies performed with clobetasol propionate gel, cream and ointment indicate that they are in the super-high range of potency as compared with other topical corticosteroids. Studies performed with halobetasol propionate cream indicate that it is in the super-high range of potency as compared with other topical corticosteroids.
The best topical steroid for a rash resistant to oral pred is likely to be either clobetasol propionate or halobetasol propionate, as both are considered super-high potency topical corticosteroids 2, 3.
- Both options are potent and may be effective for a rash resistant to oral pred.
- However, without direct comparison or further information, it is unclear which one is more effective.
- It is recommended to consult a healthcare professional to determine the best course of treatment.
From the Research
Topical Steroid Options
- Clobetasol propionate is considered the most potent of all topical steroids, with anti-inflammatory, immunosuppressive, and antimitotic effects 4
- It is successfully applied in the treatment of various skin diseases, including atopic dermatitis, psoriasis, and vulvar lichen sclerosus 4
- However, its potency is accompanied by local and systemic side effects, such as skin atrophy and hypothalamic-pituitary-adrenal axis suppression 4
Treatment of Rash Resistant to Oral Prednisone
- For rashes resistant to oral prednisone, topical corticosteroids such as clobetasol 0.05% or triamcinolone 0.1% may be effective 5
- The concentration of corticosteroid in skin, adjusted for the relative potency of the active compound, may be a predictor of clinical efficacy 6
- Data suggest that hydrocortisone 2.5% ointment, triamcinolone 0.1% ointment, and clobetasol 0.05% foam can achieve effective skin concentrations greater than the effective concentration achieved by oral prednisone 6
Alternative Topical Steroid Options
- Halobetasol propionate 0.01% lotion has been shown to be safe and effective in the treatment of moderate-to-severe plaque psoriasis, with significant reductions in the severity of clinical signs and improvements in quality of life 7
- This lotion may be a suitable alternative for patients who require long-term treatment with topical corticosteroids, as it has been shown to be well-tolerated with no treatment-related adverse events greater than 1% 7