Which topical steroids can be used safely during the periconception period?

Safe Topical Steroids During Periconception Period

Mild to moderate potency topical corticosteroids are safe to use during the periconception period and pregnancy, while potent and very potent formulations should be avoided due to risk of fetal growth restriction. 1

Recommended Safe Topical Steroids

Low to Moderate Potency Options (Preferred)

• Use Class V-VII (low potency) topical corticosteroids such as hydrocortisone 2.5% cream, desonide, or aclometasone for facial and intertriginous areas during periconception and pregnancy 2, 3
• Apply Class III-V (moderate potency) topical corticosteroids such as hydrocortisone butyrate 0.1%, prednicarbate 0.1%, or triamcinolone acetonide 0.025% for body areas when needed 2
• These formulations have not been associated with increased risk of major malformations, intrauterine growth restriction, preterm delivery, or low birthweight at usual doses 1

Evidence Supporting Safety

• A large UK cohort study of 84,133 pregnant women found no association between mild/moderate topical corticosteroids and orofacial clefts, preterm delivery, or fetal death 1
• Mild/moderate potency topical corticosteroids are preferred because they lack the fetal growth restriction risk seen with potent formulations 1

Topical Steroids to Avoid

High Potency Formulations (Avoid or Use Cautiously)

• Avoid Class I-II (potent/very potent) topical corticosteroids such as clobetasol propionate, halobetasol propionate, and betamethasone dipropionate during periconception and pregnancy 2, 1
• Potent/very potent topical corticosteroids are significantly associated with fetal growth restriction when used during pregnancy 1
• Avoid prolonged use of high-potency topical corticosteroids during pregnancy 3

Specific Agents to Avoid

• Do not use betamethasone or dexamethasone as they cross the placenta more readily and could affect the fetus 3
• If systemic corticosteroids become necessary, prednisolone is preferred as it is 90% inactivated by the placenta 3

Application Guidelines

Duration and Frequency

• Apply topical corticosteroids once or twice daily for up to 3 weeks for super-high-potency (though these should be avoided in periconception) 4
• Use for up to 12 weeks for high- or medium-potency corticosteroids under medical supervision 4
• No specified time limit exists for low-potency topical corticosteroids, making them ideal for periconception use 4

Amount and Technique

• Use the fingertip unit method for proper application: one fingertip unit (from tip of index finger to distal interphalangeal joint crease) covers approximately 2% body surface area 4, 5
• Apply sufficient medication to achieve clinical response rather than "sparingly" or "thinly" for low-potency formulations 5
• Avoid occlusive dressings during pregnancy as they increase systemic absorption 6

Special Considerations for Periconception

Preconception Period

• Switch from potent to mild/moderate potency topical corticosteroids before attempting conception if chronic use is needed 1
• Counsel women of childbearing age about medication changes that may be needed before conception 2

First Trimester

• Continue mild/moderate potency topical corticosteroids if needed for inflammatory skin conditions, as the evidence does not support increased risk of orofacial clefts 1
• A Danish cohort study did not support a causal association between topical corticosteroids and orofacial clefts 1

Adjunctive Therapies

• Apply emollients regularly, especially after bathing, to maintain skin barrier function and reduce the need for corticosteroids 3
• Use antiseptic washes like chlorhexidine or bleach baths if needed, as they are unlikely to be associated with increased pregnancy risks 2
• Avoid triclosan-containing antiseptics due to potential endocrine-disrupting effects 2

Common Pitfalls to Avoid

• Do not prescribe very potent topical corticosteroids for initial management during periconception—moderate potency is sufficient and safer 3
• Do not apply topical corticosteroids extensively over large surface areas or for prolonged periods during pregnancy, as this increases systemic absorption 6
• Do not use tight-fitting or occlusive garments over treated areas, as these constitute occlusive dressings and increase absorption 6
• Monitor for HPA axis suppression if using higher doses over large surface areas, though this is rare with appropriate low-potency use 6