What is the recommended usage of topical steroids?

Recommended Usage of Topical Steroids

Topical corticosteroids should be prescribed based on potency class (1-7), with class 1-5 (moderate to high potency) recommended for plaque psoriasis for up to 4 weeks, while using lower potency steroids for face, intertriginous areas, and regions susceptible to steroid atrophy. 1

Potency Selection Guidelines

• Potency classification:

  • Class 1: Ultra-high potency (e.g., clobetasol propionate)
  • Class 2-3: High potency (e.g., betamethasone dipropionate)
  • Class 4-5: Medium potency (e.g., fluocinolone acetonide)
  • Class 6-7: Low potency (e.g., hydrocortisone)

• Anatomical considerations:

  • Face, intertriginous areas, genitals: Low potency (classes 6-7)
  • Trunk and extremities: Medium to high potency (classes 2-5)
  • Thick, chronic plaques: Ultra-high potency (class 1)
  • Scalp: Any potency class (1-7) depending on severity 1

Duration of Treatment

• Standard treatment duration:

  • Ultra-high potency (class 1): Maximum 2-4 weeks
  • High/medium potency (classes 2-5): Maximum 4-12 weeks
  • Low potency (classes 6-7): No specified time limit 2

• Maintenance therapy:

  • After achieving treatment success, consider intermittent use (twice weekly) to reduce disease flares and relapse 1
  • For scalp psoriasis: Minimum 4 weeks for initial and maintenance treatment 1

Application Technique

• Quantity guidance:

  • Use the fingertip unit (FTU) method: amount of medication from the fingertip to first finger crease covers approximately 2% body surface area 2
  • Avoid instructions to apply "sparingly" or "thinly" as this contributes to steroid phobia and treatment failure 3

• Frequency:

  • Most conditions: Once or twice daily application
  • Once daily application may be sufficient for potent topical corticosteroids 1

Special Populations

• Children:

  • Use lowest effective potency for shortest duration
  • Monitor for potential systemic absorption, which may be proportionally larger in children 4
  • Avoid tight-fitting diapers or plastic pants when treating diaper area (creates occlusion) 4

• Pregnant/nursing women:

  • Use only if potential benefit justifies potential risk
  • Avoid extensive use in large amounts or for prolonged periods 4

Monitoring and Side Effects

• Common adverse effects:

  • Local: Skin atrophy, striae, telangiectasia, purpura, folliculitis
  • Systemic (with extensive use): HPA axis suppression, Cushing's syndrome 4

• High-risk areas:

  • Face, intertriginous areas, and chronically treated areas (especially forearms) are at greatest risk for adverse effects 1
  • Monitor for signs of local adverse reactions, especially under occlusive dressings 4

Combination Approaches

• For inadequate response to topical corticosteroids alone:
  • Consider combination with vitamin D analogues
  • Consider topical calcineurin inhibitors for face and intertriginous areas 5

Pitfalls to Avoid

• Steroid phobia: Patient fear leading to underapplication and treatment failure 3

  • Provide clear education about safety when used appropriately
  • Avoid vague instructions like "use sparingly"

• Inappropriate potency selection: Only 55.5% of patients correctly identify steroid potency 6

  • Clearly communicate potency class and appropriate use areas

• Prolonged use of high-potency steroids: Increases risk of local and systemic side effects

  • Consider steroid-sparing agents for long-term management 1
  • Implement weekend-only or intermittent application schedules for maintenance 1

By following these evidence-based guidelines, topical corticosteroids can be used effectively and safely for various dermatological conditions while minimizing the risk of adverse effects.