Are high potency steroids suitable for treating facial dermatitis?

Management of Facial Dermatitis: Appropriate Steroid Selection

Low to medium potency topical corticosteroids should be used for facial dermatitis, while high potency steroids should be avoided on the face due to increased risk of skin atrophy and other adverse effects. 1, 2

Appropriate Steroid Selection for Facial Dermatitis

Recommended Approach:

1. For facial dermatitis:

   • Use low potency (class 6-7) corticosteroids such as hydrocortisone 1% 2
   • Consider medium potency (class 4-5) for short-term use only in cases of moderate inflammation 1
   • Apply once or twice daily until significant improvement 1
   • Limit treatment duration to minimize risk of adverse effects

2. Avoid on the face:

   • High potency (class 1-3) topical steroids 1, 3
   • Prolonged use of any potency steroid
   • Occlusive dressings which increase absorption 3

Rationale and Evidence

The face has thinner skin and increased absorption compared to other body areas, making it particularly susceptible to steroid-induced adverse effects. According to the Taiwan guidelines for pediatric atopic dermatitis, "High potency TCSs in highly sensitive skin areas (face, neck, and skin folds) should be used with caution to avoid skin atrophy" 1.

The American Academy of Dermatology guidelines specifically recommend lower potency corticosteroids for facial dermatitis to minimize risks while still providing therapeutic benefit 2. This is supported by the joint AAD-NPF guidelines which state that "Lower potency corticosteroids should be used on the face, intertriginous areas, and areas that are susceptible to steroid atrophy" 1.

Steroid-Sparing Alternatives

When treating facial dermatitis, consider these alternatives:

• Topical calcineurin inhibitors (TCIs):

  • Pimecrolimus 1% cream or tacrolimus 0.03% ointment 2
  • Particularly useful for facial involvement 2
  • Can be used for longer periods without the risk of skin atrophy

• Moisturizers and barrier repair:

  • Apply frequently throughout the day 2
  • Use fragrance-free, preservative-free formulations 2
  • Apply at least 15-30 minutes before or after steroid application 2

Potential Complications of High-Potency Steroids on Face

Using high-potency steroids on facial skin can lead to:

• Skin atrophy and thinning 3
• Telangiectasia (visible blood vessels) 4
• Striae (stretch marks) 5
• Perioral dermatitis 1
• Rosacea 1
• Acne or acneiform eruptions 3

The FDA label for clobetasol (a high-potency steroid) specifically warns that "certain areas of the body, such as the face, groin, and axillae, are more prone to atrophic changes than other areas of the body following treatment with corticosteroids" 3.

Special Considerations

• Duration of treatment:

  • For facial dermatitis, limit treatment to the shortest duration needed
  • Consider proactive, intermittent application (twice weekly) for maintenance therapy in recurrent cases 1

• Monitoring:

  • Regularly assess for signs of skin atrophy, telangiectasia, or other adverse effects
  • Consider referral to dermatology if no improvement after 2 weeks of appropriate treatment 2

• Patient education:

  • Demonstrate proper application technique using the fingertip unit method 5
  • Emphasize the importance of using the correct potency steroid for facial skin
  • Explain the risks of using high-potency steroids on facial skin

By following these guidelines, facial dermatitis can be effectively managed while minimizing the risk of adverse effects associated with inappropriate steroid use.