What is the best topical steroid for treating eczema?

Best Topical Steroid for Eczema

The best topical steroid for eczema depends on severity: mild potency for mild eczema (such as hydrocortisone 1%), moderate potency for moderate eczema, and potent preparations for severe eczema, using the least potent preparation required to control symptoms. 1

Selecting the Right Topical Corticosteroid

Based on Eczema Severity

• Mild eczema: Low potency (e.g., hydrocortisone 1% cream)
• Moderate eczema: Moderate potency (e.g., prednicarbate 0.02% cream)
• Severe eczema: Potent preparations
• Very severe or resistant eczema: Very potent preparations (for limited periods only)

Based on Body Location

• Face and neck: Mild potency (hydrocortisone 1%)
• Body: Moderate to potent preparations
• Hands and feet: Potent preparations may be needed due to thicker skin

Application Guidelines

• Apply topical steroids twice daily for 1-2 weeks until improvement 1
• Once-daily application of potent topical corticosteroids is as effective as twice-daily application 2
• Use the fingertip unit method for appropriate dosing
• For maintenance, consider weekend therapy (Saturday and Sunday only) to prevent relapse 1

Safety Considerations

• Potent and very potent preparations should be used with caution and for limited periods only 3
• The main risk of topical corticosteroids is suppression of the pituitary-adrenal axis with possible interference of growth in children 3
• Risk of skin thinning is low (only 1% across 22 trials) but increases with higher potency steroids 2
• Short-term use (3 days) of potent topical corticosteroids can be as effective as prolonged use (7 days) of mild preparations for children with mild to moderate eczema 4

Complementary Treatments

Moisturizers and Emollients

• Apply emollients liberally and frequently, especially after bathing 1
• Use 15-30 minutes before or after steroid application 1
• Use dispersible cream as a soap substitute to cleanse the skin 3

Alternative Topical Treatments

• Pimecrolimus (Elidel) cream 1% can be used for mild to moderate eczema as an alternative to topical corticosteroids, but is less effective than moderate and potent corticosteroids 5
• Tacrolimus 0.1% is ranked among the most effective topical treatments alongside potent steroids 6
• Ichthammol (less irritant than coal tar) can be useful for lichenified eczema 1

Managing Infection

• Antibiotics are important for treating secondary bacterial infection 3
• Flucloxacillin is usually most appropriate for treating Staphylococcus aureus (most common pathogen) 3
• Phenoxymethylpenicillin for B-hemolytic streptococci infections 3
• Erythromycin when there is resistance to flucloxacillin or penicillin allergy 3

Common Pitfalls to Avoid

• Undertreatment: 72.5% of patients worry about using topical corticosteroids, with 24% admitting non-compliance due to these concerns 7
• Overuse of potent steroids: Use the least potent preparation required to keep eczema under control 1
• Ignoring maintenance therapy: Consider weekend therapy to prevent relapse after initial control 1
• Neglecting moisturizers: Regular use of emollients is essential alongside steroid treatment 1

Recent evidence from a 2024 Cochrane systematic review and network meta-analysis confirms that potent topical steroids, Janus kinase inhibitors, and tacrolimus 0.1% are consistently ranked among the most effective topical anti-inflammatory treatments for eczema 6.