From the Guidelines
High-potency steroid creams can potentially cause systemic side effects like weakness and weight loss when used extensively over large body areas or for prolonged periods, as evidenced by the suppression of the hypothalamic-pituitary-adrenal axis, leading to reduced natural cortisol production, muscle catabolism, and metabolic changes 1.
Mechanism and Risk Factors
The mechanism involves the absorption of topical steroids through the skin into the bloodstream, leading to systemic effects similar to those of oral steroids. Medications like clobetasol propionate (Dermovate), betamethasone dipropionate, and fluocinonide are examples of high-potency topical steroids that pose greater risk. These side effects typically develop with prolonged use (weeks to months) of large amounts (more than 50g weekly) or when applied under occlusion. The risk increases when applied to thin skin areas or on broken skin.
Minimizing Risks
To minimize risks, it is recommended to:
- Use the lowest effective potency
- Apply only to affected areas
- Follow prescribed duration (usually 2-4 weeks maximum for high-potency steroids)
- Consider periodic breaks in treatment If you experience weakness, unexplained weight loss, or other unusual symptoms while using topical steroids, consult your healthcare provider immediately.
Recent Guidelines
Recent guidelines from the Journal of the American Academy of Dermatology 1 suggest that high-potency steroids can be effective for treating severe disease and flares, but emphasize the importance of using the lowest potency needed for the situation and increasing potency if needed. The guidelines also recommend intermittent use of medium potency TCS as maintenance therapy to reduce disease flares and relapse.
Adverse Effects
Adverse effects of topical steroids, including skin atrophy, purpura, telangiectasia, hypopigmentation, focal hypertrichosis, acneiform eruptions, and striae, are generally low, but can be concerning for physicians and patients 1. Steroid Addiction (TSA) and Topical Steroid Withdrawal (TSW) are less clearly characterized in the literature, but prolonged, inappropriate use of potent topical steroids on the face or in intertriginous areas is a consistent risk factor.
From the FDA Drug Label
HPA axis suppression, Cushing's syndrome, linear growth retardation, delayed weight gain and intracranial hypertension have been reported in children receiving topical corticosteroids Manifestations of adrenal suppression in children include low plasma cortisol levels, and an absence of response to ACTH stimulation.
The use of high-potency steroid creams like clobetasol propionate can lead to adrenal suppression, which may cause muscle weakness and weight loss in some cases, particularly in pediatric patients. However, this is more directly related to HPA axis suppression and Cushing's syndrome, which can have various symptoms including weight changes and muscle weakness. 2
From the Research
High-Potency Steroid Creams and Their Side Effects
- High-potency steroid creams, such as those containing clobetasol or betamethasone, can have unwanted side effects, including skin hypopigmentation, atrophy, and acneiform eruptions 3.
- The use of high-potency topical steroids can also lead to systemic side effects, such as adrenal insufficiency, although this is less common in patients with intact cutaneous barrier 4.
- Local side effects, such as perianal ulcerations, can occur with the use of high-potency topical steroids in intertriginous areas 5.
Muscle Weakness and Weight Loss
- There is no direct evidence in the provided studies to suggest that high-potency steroid creams can cause muscle weakness and weight loss.
- However, systemic side effects, such as adrenal insufficiency, can occur with the use of high-potency topical steroids, which may lead to symptoms such as muscle weakness and weight loss 4.
- Further studies are needed to fully understand the potential side effects of high-potency steroid creams and their impact on overall health 3, 6, 7.
Safe Use of High-Potency Steroid Creams
- High-potency topical steroids should be used sparingly and briefly in intertriginous areas to minimize the risk of local side effects 5.
- Doses of 50 g or less per week of clobetasol during a period of 12 weeks are considered safe for adult vitiligo patients, although local side effects are possible 4.
- The use of high-potency steroid creams should be monitored closely, and patients should be aware of the potential side effects and report any concerns to their healthcare provider 3, 6, 7.