What is the recommended potency of steroid cream for various skin conditions?

Recommended Potency of Steroid Cream for Various Skin Conditions

The appropriate potency of topical corticosteroids should be selected based on the specific skin condition, location, severity, and patient characteristics, with moderate to high potency (classes 2-5) generally recommended as initial therapy for most adult plaque psoriasis, while using lower potency steroids for sensitive areas like the face and intertriginous regions. 1

General Principles of Topical Steroid Selection

• Topical corticosteroids are classified into 7 categories based on their vasoconstrictive activity, ranging from ultra-high potency (class 1) to low potency (classes 6 and 7) 1
• Selection should consider disease severity, location, patient preference, and patient age 1
• Lower potency corticosteroids should be used on the face, intertriginous areas, and areas susceptible to steroid atrophy (e.g., forearms) 1
• Treatment duration should generally be limited, with ultra-high potency steroids restricted to 2 consecutive weeks and amounts not exceeding 50g per week 2

Recommendations by Skin Condition

Psoriasis

• For plaque psoriasis not involving intertriginous areas:

  • Classes 1-2 (ultra-high to high potency): Recommended for thick, chronic plaques 1
  • Classes 2-5 (high to moderate potency): Recommended as initial therapy for most adult cases 1
  • Treatment duration: Up to 4 weeks is recommended 1

• For scalp psoriasis:

  • Classes 1-7 (any potency): Recommended for minimum of up to 4 weeks for initial and maintenance treatment 1

Atopic Dermatitis/Eczema

• For mild disease:

  • Low to moderate potency steroids are appropriate 1
  • Very potent topical steroids should be avoided 1

• For moderate to severe disease:

  • Medium potency steroids can be utilized for longer courses due to more favorable adverse event profile 1
  • High potency steroids are useful for treating severe disease and flares 1
  • Very high potency steroids (clobetasol propionate, fluocinonide, halobetasol propionate) can effectively control severe flares 1
  • Once-daily application of potent steroids is likely as effective as twice-daily application 3

Bullous Pemphigoid

• For localized or mild disease:

  • Very potent topical steroids alone applied to lesional skin (strength of recommendation A) 1

• For moderate-to-severe disease:

  • Very potent topical steroids 5-15g twice daily to whole skin surface if patient/carer is capable (strength of recommendation A) 1

Vitiligo

• For recent onset:
  • Potent or very potent topical steroid for a trial period of no more than 2 months 1
  • Topical pimecrolimus or tacrolimus should be considered as alternatives due to better short-term safety profile 1

Hand-Foot Skin Reactions (from cancer treatments)

• For grade 1-2 reactions:

  • High-potency topical steroids twice daily 1

• For grade ≥3 or intolerable grade 2:

  • High-potency topical steroids twice daily, with treatment interruption until severity decreases 1

Application Frequency and Duration

• For most conditions, once or twice daily application is recommended 3
• For eczema, once-daily application of potent topical corticosteroids is likely as effective as twice-daily application 3
• For prevention of eczema flares, weekend therapy (proactive approach) with topical corticosteroids is more effective than reactive use 3
• Ultra-high potency steroids (class 1) should be limited to 2 consecutive weeks of treatment 2
• Longer-term use of topical corticosteroids (>12 weeks) can be considered under careful physician supervision 1

Common Pitfalls and Caveats

• Avoid using high potency steroids on the face, intertriginous areas, and areas susceptible to steroid atrophy 1
• Be aware of potential side effects, particularly skin atrophy with prolonged use of higher potency steroids 3
• Clobetasol propionate and other super-high potency formulations should not be used with occlusive dressings 2
• Pediatric patients under 12 years of age should not use super-high potency corticosteroids 2
• Undertreatment due to steroid phobia is common; proper education about benefits and risks is important 1
• Even low-potency glucocorticosteroids can broadly affect immune and barrier responses in moderate-to-severe atopic dermatitis when used consistently 4

By selecting the appropriate potency of topical corticosteroid based on the specific skin condition, location, and patient characteristics, clinicians can maximize therapeutic benefits while minimizing potential adverse effects.