Topical Steroids for Facial Use
For skin conditions on the face, low-potency topical corticosteroids such as hydrocortisone 1% should be used as first-line treatment, with preservative-free dexamethasone 0.1% reserved for moderate-to-severe cases requiring short-term use only. 1
Potency Selection Based on Facial Application
- Low-potency topical corticosteroids (Class VI-VII) such as hydrocortisone 1% are recommended for facial skin due to the thin skin in these areas and increased risk of adverse effects 1, 2
- The face, neck, genitals, and body folds require lower potency agents compared to trunk and extremities due to increased absorption and risk of side effects 2
- Avoid medium to high potency corticosteroids on facial skin as they can lead to significant adverse effects including skin atrophy, telangiectasias, and hypopigmentation 3, 4
Application Guidelines
- Apply topical corticosteroids after bathing when skin is slightly damp for better absorption 1
- Use the "fingertip unit" method for appropriate dosing - one fingertip unit covers approximately 2% body surface area 5, 6
- Apply thinly but adequately to cover the affected area - the traditional advice to apply "sparingly" may lead to undertreatment 5
- For facial application, do not use occlusive dressings as they increase absorption and risk of side effects 3
Duration of Treatment
- Limit treatment with topical corticosteroids on the face to short courses to control flares 1, 7
- For moderate-to-severe periocular eczema requiring dexamethasone 0.1%, limit treatment to a maximum of 8 weeks 1
- Consider early introduction of steroid-sparing agents (tacrolimus ointment) to facilitate tapering of corticosteroids 1, 2
- Low-potency corticosteroids can be used for longer periods compared to higher potency ones 6
Specific Conditions and Recommendations
- For atopic dermatitis/eczema: Use Class VI-VII (low potency) corticosteroids like hydrocortisone 1% 7, 2
- For acne: Topical corticosteroids are NOT recommended as primary treatment and can worsen acne with prolonged use 4, 8
- For inflammatory nodulocystic acne: Intralesional triamcinolone acetonide (2.5-5 mg/mL) may be used for individual lesions, but not as a general facial treatment 7
Monitoring and Side Effects
- Monitor for signs of skin atrophy, telangiectasia, striae, or acneiform eruptions 3
- Common adverse effects of inappropriate facial corticosteroid use include steroid rosacea, perioral dermatitis, acneiform eruptions, and hypertrichosis 4, 8
- "Topical steroid dependent face" can develop with prolonged use, causing erythema, burning, and itching when stopping application 4
- Preservative-free formulations are recommended for periocular use due to increased risk of allergic contact dermatitis 1
Adjunctive Therapies
- Use emollients regularly as soap substitutes and moisturizers 7, 1
- Apply emollients at least 30 minutes before or after topical corticosteroids 1
- For severe pruritus, sedating antihistamines may be useful as a short-term adjuvant during flares 7
- Consider steroid-sparing alternatives like tacrolimus 0.03% or 0.1% ointment, pimecrolimus 1% cream for facial application 2
Common Pitfalls to Avoid
- Avoid using medium to high potency corticosteroids (Classes I-V) on facial skin 2, 4
- Do not use topical corticosteroids as general cosmetic creams or for hyperpigmentation 4, 8
- Avoid prolonged continuous use on the face as this increases risk of adverse effects 3, 4
- Do not use soaps and detergents on affected facial skin as they remove natural lipids from the skin surface 7
- Discontinue topical corticosteroids if signs of infection develop and treat the infection appropriately 7
When to Refer
- If no improvement after 4 weeks of appropriate treatment, consider referral to a dermatologist 1
- For treatment-resistant facial dermatoses, consider referral for evaluation of alternative diagnoses or treatments 1
- If signs of significant adverse effects develop (severe atrophy, widespread telangiectasia), seek dermatology consultation 4