Potency of a topical corticosteroid preparation is a result of the formulation as well as the corticosteroid. The potency of steroid should be matched to the severity of the disease, using the least potent steroid that effectively controls the disease.

Do not use:

• potent or very potent topical corticosteroids on the face or neck
• potent topical corticosteroids in children under 12 months without specialist dermatological supervision
• very potent topical steroids in children without specialist dermatological advice

The preferred formulation for corticosteroids is usually ointment as they are more moisturising than cream, and contain less or no preservatives.

The advantages of including other substances (such as antibacterials or antifungals) with steroids in topical preparations are debatable, but they may have a place where there is associated bacterial or fungal infection.

NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). One of these conditions is mild irritant dermatitis.

Many of these products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

MHRA Drug Safety Update (September 2021 & May 2024): topical corticosteroids: reminder of the possibility of severe side effects, including Topical Steroid Withdrawal Reactions

• Long-term continuous (generally 6 months or more) or inappropriate use of moderate to high potency topical corticosteroids can result in the development of rebound flares after stopping treatment, often referred to as ‘Topical Steroid Withdrawal Reactions’ (TSW). Symptoms include intense redness, stinging, and burning that can spread beyond the initial treatment area.
• TSW reactions are estimated to be rare and should be put into context of the millions of people that have benefitted from topical steroid treatment without experiencing any problems.
• When prescribing a topical corticosteroid:
  • consider the lowest potency needed. Different potency products may be required for different body areas. Topical steroids will be labelled with their potencies to aid correct selection by patients requiring multiple products of different potency.
  • advise on the amount of product to apply, how often, where to apply it and when to stop treatment (especially on sensitive areas such as the face and genitals)
  • inform patients to return for medical advice if their skin condition worsens while using topical corticosteroid, and advise them when it would be appropriate to re-treat without a consultation
• If previous discontinuation of topical corticosteroids was associated with a suspected TSW reaction, consider alternative treatments.
• For patients currently on long-term topical corticosteroid treatment, consider reducing potency or frequency of application (or both)
  
• Be vigilant for the signs and symptoms of TSW reactions and review the position statement from the National Eczema Society and the British Association of Dermatologists
• For advice to give to patients and carers, see the safety update and the Patient Safety Leaflet on TSW reactions developed by the MHRA. If appropriate, advise on symptoms of adrenal suppression.

Suitable quantities of corticosteroid preparations

Topical corticosteroid preparations should be applied no more frequently than twice daily; once daily is often sufficient.

Topical corticosteroids should be spread thinly on the skin but in sufficient quantity to cover the affected areas. The length of cream or ointment expelled from a tube may be used to specify the quantity to be applied to a given area of skin. This length can be measured in terms of a fingertip unit (the distance from the tip of the adult index finger to the first crease). One fingertip unit (approximately 500 mg from a tube with a standard 5 mm diameter nozzle) is sufficient to cover an area that is twice that of the flat adult handprint (palm and fingers).

See below for the quantities that should be sufficient for two weeks treatment of once daily application.

Mild

Hydrocortisone

• Ointment 1% (£5.16 = 30g)
• Cream 1% (£4.83 = 30g)

Indications

• Mild eczema
• Flexural, genital, and facial psoriasis

Dose

• Apply thinly once or twice daily

Notes

1. Hydrocortisone ointment and cream (1%) is available over the counter, at lower cost than a prescription, for the treatment of allergic contact dermatitis, irritant dermatitis, insect bite reactions and mild to moderate eczema. It cannot be sold for application to eyes/face, anogenital region, on broken or infected skin or for use in pregnancy or children under 10 years.

Mild with antimicrobials / antifungals

Fucidin H

(Fusidic acid 2% / hydrocortisone 1%)

• Cream (£6.02 = 30g)

Indications

• Infected eczema (localised infection)

Moderate

Eumovate

(Clobetasone butyrate 0.05%)

• Ointment (£1.86 = 30g)
• Cream (£1.86 = 30g)

Indications

• Moderate eczema
• Flexural, genital, and facial psoriasis

Dose

• Apply thinly once or twice daily

Notes

1. Eumovate cream can be sold over the counter, at lower cost than a prescription, for short-term symptomatic treatment and control of patches of eczema and dermatitis (but not seborrhoeic dermatitis) in adults and children over 12 years.

Betnovate RD

(Betamethasone valerate 0.025%)

• Ointment (£3.15 = 100g)
• Cream (£3.15 = 100g)

Indications

• Moderate eczema
• Flexural, genital, and facial psoriasis

Dose

• Apply thinly once or twice daily

Fludroxycortide

• Cream 0.0125% (£12.49 = 60g)
• Tape 4micrograms/cm² (£32.52 = 7.5cm x 50cm)

Indications and dose

• Cream: Inflammatory skin disorders such as eczema
  • Apply thinly once or twice daily
• Tape: Chronic localised recalcitrant dermatoses (but not acute or weeping)
  • Cut tape to fit lesion and apply to clean, dry skin shorn of hair, usually for 12 hours daily

Notes

1. Tape may be useful for hand eczema and localised skin cracks

Moderate with antimicrobials / antifungals

Trimovate

(Combination of clobetasone butyrate 0.05% w/w, oxytetracycline 3.0% w/w, and nystatin 100,000 units per gram)

• Cream (£14.99 = 30g)

Indications

• Treatment and management of steroid responsive dermatoses where candidal or bacterial infection is present, suspected or likely to occur

Dose

• Apply thinly once or twice a day for up to 7 days

Potent

Betamethasone valerate 0.1%

• Ointment 0.1% (£1.60 = 30g)
• Cream 0.1% (£2.62 = 30g)
• Scalp application (aqueous) 0.1% (£3.94 = 100ml)

Indications

• Severe eczema
• Psoriasis

Dose

• Apply thinly once or twice daily

Notes

1. Not licensed for use in children under 1 year

Mometasone furoate

• Ointment 0.1% (£3.29 = 30g)
• Cream 0.1% (£3.56 = 30g)
• Scalp lotion 0.1% (£4.36 = 30ml)

Indications

• Severe eczema
• Psoriasis

Dose

• Apply thinly once or twice daily

Potent with antimicrobials / antifungals

Fucibet

(Betamethasone valerate 0.1% / fusidic acid 2%)

• Cream (£6.38 = 30g)

Indications

• Infected eczema (localised infection)

Potent with salicylic acid

Diprosalic

(Betamethasone 0.05% / salicylic acid 3%)

• Scalp application (£10.10 = 100ml)

Indications

• Severe inflammatory skin disorders

Very potent

Due to the risk of potential errors, clobetasol preparations should be prescribed by brand

If treatment with a local corticosteroid is clinically justified beyond 4 weeks, a less potent corticosteroid preparation should be considered.

Dermovate

(Clobetasol propionate 0.05%)

• Ointment (£2.69 = 30g)
• Cream (£2.69 = 30g)
• Scalp application (£3.07 = 30ml)

Indications

• Severe eczema
• Psoriasis

Dose

• Apply thinly once or twice daily for up to 4 weeks

Etrivex

(Clobetasol propionate 0.05%)

• Shampoo 500micrograms/g (£9.15 = 125ml)

Indications

• Scalp psoriasis

Dose

• Apply thinly once or twice daily (twice daily dose is unlicensed) for 2 weeks. Shampoo should be rinsed off after 15 minutes