What are the dosing options for topical steroids higher than medium potency?

Dosing Options for High and Very High Potency Topical Steroids

For conditions requiring topical steroids higher than medium potency, use high potency (class I-II) topical corticosteroids twice daily for 2-3 weeks, with a maximum of 50g per week, followed by a taper to maintenance therapy. 1, 2

High and Very High Potency Topical Steroid Options

Class I (Very High Potency)

• Clobetasol propionate 0.05% (cream, ointment, gel)
  • Apply thin layer twice daily
  • Maximum treatment duration: 2 consecutive weeks
  • Maximum weekly amount: 50g
  • Do not use with occlusive dressings 2

Class II (High Potency)

• Fluocinonide 0.05% (cream, ointment)
  • Apply thin layer twice daily
  • Treatment duration: 2-4 weeks
  • Avoid occlusive dressings unless specifically directed 3
  • Less potent than clobetasol (clobetasol is 5-6 times more potent than hydrocortisone, while fluocinonide is less potent) 4, 5

Application Guidelines

1. Initial Treatment Phase:

   • Apply a thin layer to affected areas twice daily
   • Rub in gently and completely
   • Continue for 2-3 weeks for high potency steroids 1
   • For very high potency (clobetasol), limit to 2 weeks maximum 2

2. Maintenance Phase:

   • After achieving control, transition to maintenance therapy
   • Apply high potency steroid 2-3 times weekly to prevent recurrence 1
   • Medium potency steroids can be utilized for longer courses due to more favorable adverse event profiles 1

Anatomical Considerations

• Use lower potency agents on:

  • Face
  • Neck
  • Genitals
  • Body folds 1

• Higher potency can be used on:

  • Palms and soles (thicker skin)
  • Trunk
  • Extremities (except flexural areas) 1

Monitoring and Precautions

• Watch for local adverse effects:

  • Skin atrophy
  • Telangiectasia
  • Striae
  • Purpura 1

• Systemic adverse effects risk increases with:

  • Application to large surface areas
  • Prolonged use
  • Occlusive dressings
  • Higher potency steroids 2, 3

• HPA axis suppression:

  • Monitor for signs of Cushing's syndrome with prolonged use
  • Consider morning plasma cortisol or ACTH stimulation tests for patients using large amounts 2

Special Considerations

• Tachyphylaxis:

  • May occur with prolonged use
  • Consider intermittent application schedules to minimize this risk 1

• Pediatric patients:

  • More susceptible to systemic effects due to larger skin surface to body mass ratio
  • Use lower potency steroids when possible 2

• Vehicle selection:

  • Ointments: Better for dry, scaly conditions (higher potency)
  • Creams: Better for weeping lesions
  • Gels/solutions: Better for hairy areas 6

Quantity Guidelines

For a 2-week treatment period, approximate amounts needed:

• Face and neck: 15-30g
• Both hands: 15-30g
• Both arms: 30-60g
• Both legs: 100g
• Trunk: 100g 7

High and very high potency topical steroids are effective but require careful monitoring and limited duration of use to minimize adverse effects. After the initial treatment phase, transition to maintenance therapy with medium potency steroids or intermittent application of high potency steroids to prevent recurrence.