What is the strongest topical steroid?

The Strongest Topical Steroid

Clobetasol propionate 0.05% is the strongest topical corticosteroid available, classified as a class I (superpotent) steroid with the highest potency among all topical steroids. 1, 2, 3

Classification of Topical Steroids

Topical corticosteroids are classified based on their potency into 7 classes:

1. Class I (Superpotent)

   • Clobetasol propionate 0.05%
   • Halobetasol propionate 0.05%

2. Class II (Potent)

   • Betamethasone dipropionate 0.05% (optimized)
   • Fluocinonide 0.05%

3. Class III-IV (Upper-midstrength to Midstrength)

   • Triamcinolone acetonide 0.1%
   • Fluticasone propionate 0.05%

4. Class V-VII (Lower-midstrength to Least potent)

   • Hydrocortisone 1.0%
   • Clobetasone butyrate 0.05%

Evidence of Potency

Clinical studies have demonstrated the superior potency of clobetasol propionate:

• Efficacy rates for class I (superpotent) steroids range from 58%-92% in treating psoriasis, significantly higher than lower potency classes 4
• In direct comparisons, clobetasol propionate showed greater improvement than betamethasone dipropionate (a class II steroid) 5
• Pharmacologic studies confirm clobetasol propionate is in the "super-high range of potency" compared to other topical corticosteroids 1

Clinical Applications

Superpotent steroids like clobetasol propionate are indicated for:

• Moderate to severe plaque psoriasis (not involving intertriginous areas) 4
• Lichen sclerosus 4, 6
• Severe, steroid-responsive dermatoses resistant to lower-potency steroids 7

Important Limitations and Safety Considerations

Due to their high potency, superpotent steroids have significant restrictions:

• Duration: Should not be used for more than 2-4 weeks continuously 4, 1
• Quantity: Only small areas should be treated at any one time 1
• Location: Should not be used on the face, groin, or axillae 1
• Monitoring: Patients applying to large surface areas should be evaluated for HPA axis suppression 1

Adverse Effects

The potency of clobetasol propionate comes with increased risk of side effects:

• Local: Skin atrophy, striae, telangiectasia, purpura, folliculitis 4, 1
• Systemic: HPA axis suppression, Cushing's syndrome, hyperglycemia (with extensive use) 1
• Rebound: Abrupt discontinuation may lead to disease recurrence that is more severe than before treatment 4

Practical Application

For optimal use of superpotent steroids:

1. Apply a thin layer to affected areas only
2. Use for limited duration (2-4 weeks maximum)
3. Consider tapering (e.g., reducing to alternate-day application before discontinuation)
4. For maintenance, transition to a lower-potency steroid when possible 6

Pediatric patients may be more susceptible to systemic toxicity due to their larger skin surface to body mass ratio, requiring extra caution when using superpotent steroids in this population 1.