From the Guidelines
Long-term use of topical betamethasone can lead to significant side effects, including skin atrophy, striae, telangiectasia, and purpura, particularly when used on the face, intertriginous areas, or with occlusion, as noted in the 2023 guidelines of care for the management of atopic dermatitis in adults with topical therapies 1. The most common local skin adverse effects of topical corticosteroid use, such as betamethasone, include skin atrophy, striae, folliculitis, telangiectasia, and purpura, with face and intertriginous areas being at greatest risk to develop these adverse effects 1. Some key points to consider when using topical betamethasone include:
- Risk factors for atrophy include higher potency TCS use, occlusion, use on thinner and intertriginous skin, older patient age, and long-term continuous use 1.
- Allergic contact dermatitis to TCS or other ingredients in their formulations can be determined via patch testing 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 1. To minimize these risks, betamethasone should be used at the lowest effective dose for the shortest duration necessary, with periodic breaks in treatment for chronic conditions, and patients should be monitored regularly for side effects, especially when treatment extends beyond two weeks 1. Additionally, the use of combination therapies, such as calcipotriene/betamethasone dipropionate, may help reduce the risk of cutaneous atrophy and minimize the amount and frequency of potent topical corticosteroids used 1. It is also important to consider alternative treatments, such as topical tacrolimus, for intertriginous psoriasis, and to use lower potencies of topical corticosteroids or dilute calcipotriene with a moisturizer to minimize irritation and toxicity in sensitive areas 1.
From the FDA Drug Label
The following local adverse reactions are reported infrequently with topical corticosteroids, but may occur more frequently with the use of occlusive dressings. These reactions are listed in an approximate decreasing order of occurrence: burning, itching, irritation, dryness, folliculitis, hypertrichosis, acneiform eruptions, hypopigmentation, perioral dermatitis, allergic contact dermatitis, maceration of the skin, secondary infection, skin atrophy, striae and miliaria. Patients receiving a large dose of a potent topical steroid applied to a large surface area should be evaluated periodically for evidence of HPA axis suppression by using the urinary free cortisol and ACTH stimulation tests. If HPA axis suppression is noted, an attempt should be made to withdraw the drug, to reduce the frequency of application, or substitute to a less potent steroid Side effects of long-term use of topical betamethasone include:
- Burning
- Itching
- Irritation
- Dryness
- Folliculitis
- Hypertrichosis
- Acneiform eruptions
- Hypopigmentation
- Perioral dermatitis
- Allergic contact dermatitis
- Maceration of the skin
- Secondary infection
- Skin atrophy
- Striae
- Miliaria
- HPA axis suppression 2 Key considerations:
- Pediatric patients may be more susceptible to systemic toxicity and HPA axis suppression due to a larger skin surface area to body weight ratio 2
- Chronic corticosteroid therapy may interfere with the growth and development of children 2
From the Research
Side Effects of Long-Term Use of Topical Betamethasone
- Skin atrophy is one of the most prevalent side-effects of topical glucocorticoids, including betamethasone, with changes found in all skin compartments 3
- The structure and function of the epidermis is altered even in the short-term topical glucocorticoid treatment, affecting skin barrier integrity 3
- Atrophogenic changes can be found in hair follicles, sebaceous glands, or dermal adipose tissue due to topical glucocorticoid treatment 3
- An animal model demonstrated corticosteroid-induced skin atrophy and telangiectasia, with 0.1% betamethasone valerate cream showing moderate severity of side-effects 4
- A systematic review found that intermittent use of topical corticosteroids, including betamethasone, probably results in little to no difference in risk of skin atrophy when used to treat flares 5
- A study comparing pimecrolimus and betamethasone found that betamethasone led to epidermal thinning, while pimecrolimus improved the epidermal barrier without causing atrophy 6
Specific Effects on Skin Barrier
- Topical betamethasone can alter the skin barrier, leading to changes in stratum corneum hydration and transepidermal water loss 6
- Electron microscopic evaluation showed inconsistent extracellular lipid bilayers and only partially filled lamellar bodies after betamethasone treatment, indicating a negative effect on barrier structure 6
- Betamethasone was superior in reducing clinical symptoms and epidermal proliferation, but its use led to epidermal thinning, making it less suitable for long-term treatment of atopic dermatitis 6