Topical Corticosteroid Potency Classification in Indian Practice
Indian dermatology follows the internationally recognized 7-class potency classification system, ranging from Class 1 (ultra-high potency) to Class 7 (very low potency), identical to the American Academy of Dermatology framework. 1
Standard Potency Classification System
Indian dermatologists utilize the same classification structure used globally, organized as follows:
Class 1 (Ultra-High Potency)
- Clobetasol propionate 0.05% 1
- Halobetasol propionate 0.05% 1
- Efficacy: 58-92% 1
- Maximum duration: 2-4 weeks continuous use, ≤50 grams weekly 1
Class 2 (High Potency)
Classes 3-4 (Medium Potency)
- Betamethasone valerate 1
- Fluticasone propionate 0.005% 1
- Triamcinolone acetonide 0.1% 2
- Efficacy: 68-72% 1
- Can be used for longer courses (up to 12 weeks under supervision) with more favorable adverse event profile 1
Classes 5-7 (Low Potency)
Site-Specific Selection Guidelines
Sensitive Areas (Face, Genitals, Intertriginous Zones)
- Use ONLY Classes 5-7 (low potency) due to increased absorption and atrophy risk 1, 3
- Hydrocortisone 1-2.5% cream is the most appropriate for facial conditions, applied twice daily for 2-3 weeks 3
- Never apply Class 1 steroids to face or body folds—all users developed atrophy with clobetasol after only 8 weeks 1
Trunk and Limbs
- Start with Class 2-3 (high potency) such as betamethasone dipropionate 0.05% or fluocinonide 0.05%, applied once or twice daily 1
Thick, Chronic Plaques (Palms, Soles)
- Require ultra-high potency (Class 1) corticosteroids like clobetasol propionate 0.05% for adequate penetration 1
- Low-to-medium potency agents are ineffective in these locations 1
Critical Safety Considerations
Duration Limits
- Class 1: Maximum 2-4 weeks continuous use 1
- Classes 2-5: Can be used up to 4 weeks for plaque psoriasis 1
- Medium potency (Classes 3-5): May extend to 12 weeks under careful supervision 1
Adverse Effects
- Skin atrophy occurred in only 1% of 2,266 participants across 22 trials, with just 2 cases linked to Class 4 steroids 1
- Class 1 steroids used for 4 months can cause hypertrichosis and acne 1
- Risk increases with higher potency, longer duration, larger areas, and sensitive sites 1
Pediatric Patients
- Use lower potency agents (Class 6-7) due to higher skin-surface-to-body-mass ratio and greater systemic absorption 1
- Minimal risk of HPA axis suppression with Class 6 steroids 1
Geriatric Patients
- Class 6-7 (low potency) recommended for face, neck, and intertriginous zones due to thin, atrophy-prone skin 1
- Thin, sun-damaged forearm skin requires low-to-medium potency agents 1
Common Pitfalls in Indian Practice
Prescribing Deficiencies
- A 2013 Indian study found 94.36% of prescriptions contained very potent steroids, often inappropriately 4
- 85% of prescriptions lacked diagnosis, and almost all omitted strength, quantity, frequency, site, and duration 4
- This pattern leads to misuse and increased adverse effects 4
Tachyphylaxis Misconception
- A 12-week study found no evidence of true receptor down-regulation (tachyphylaxis) with continuous use 1
- Apparent loss of efficacy is due to poor adherence, not pharmacologic dysfunction 1
- When response is inadequate, increase potency or improve adherence—do not switch to lower potency 1
Application Guidelines
Formulation Selection
- Creams for weeping/acute conditions; ointments for dry/chronic conditions 3
- Avoid alcohol-containing gels as they enhance dryness 3
Frequency
- Most studies support twice-daily application, though once-daily may suffice for potent steroids 5
- Apply after bathing when skin is slightly damp to enhance absorption 3