Topical Use of Steroid in Dermatological Condition

Topical Use of Steroid in Dermatological Condition: To Use or Not To Use?

Steroid medication is often labelled as a ‘bad’ medication with numerous side effects. Then why do doctors still prescribe this medication to patients?

In this article, we will clarify some pressing questions that the public may have regarding topical steroids. We also hope to encourage patients to consider the appropriate use of topical steroids in order to achieve treatment control of dermatological conditions.

What are topical steroids?

Topical steroids are steroid medications applied to the skin surfaces and are usually prescribed as a treatment for skin disorders. 

There are 3 main functions of topical steroid creams: 

• Anti-inflammation: targets skin conditions that are flared due to inflammation such as dermatitis [1]. 
• Immunosuppressive: will control reactions from autoimmune disorders such as autoimmune hives [2].
• Vasoconstrictive: constraints tiny blood vessels known as capillaries and aids in the reduction of swelling and pain. 

Upon usage of the right type and amount of topical steroid, one may notice alleviation of skin symptoms such as itch or burning sensation.

What are the types of topical steroids?

You may notice that your doctor prescribes you various tubes of medication with various colour coding. In general, topical steroids are categorised based on their strength or potency and formulation. The higher the potency or strength of the topical steroid, the more effective it is to reduce inflammation.

Steroid potency

Mild

Moderate

Potent

Superpotent

Topical steroids can be further subdivided depending on their formulation, this is also known as the ‘vehicle’ of the topical steroids. Different areas of the skin have different levels of thickness, as such, it is important to use the appropriate formulation to ensure sufficient penetration and absorption of the medication into the skin.

Vehicle/formulation of the steroid	Where is it suitable for
Lotion	Areas with more hair follicles – face, scalp
Cream	Moist and weepy areas
Ointment	Dry and thick skin

Your doctor will guide you on which type of topical steroid is advisable based on your individual skin condition. Do speak to your doctor if you are unsure which type of topical steroids is suitable for you.

What are the side effects of topical steroids?

There are potential side effects to topical steroid application known as local or systemic side effects of steroids. Local side effects are defined as side effects that are localised on the affected skin area that was exposed to steroids. Systemic side effects, on the other hand, are side effects that affect a person’s overall body and internal organs.

Local side effects	Systemic side effects
Initial stinging/burning sensationSkin thinning/atrophyStretch marksBruisingThin blood vessels (telangiectasia)Hair growthWorsening of acne/rosacea/perioral dermatitis	Fluid retentionElevated blood pressureOsteoporosisCushing’s syndrome

What are topical steroid withdrawal (TSW) symptoms?

There are also multiple discussions on topical steroid withdrawal (TSW) [3], also known as red skin syndrome. These are a sub-section of patients who face extreme side effects when discontinuing the use of topical steroids. Some have even documented their journey of withdrawing from steroid treatment and their remorse for using them in the first place. So how can something so “bad” be a good idea to begin with?

TSW is a cluster of symptoms that occur when an individual develops a physical dependence on the topical steroid. This tends to occur in situations when a person has been using topical steroids for prolonged periods inappropriately, using moderate to high potency steroids, or excessive frequency usage of topical steroids. 

Rebounding or ‘withdrawal’ symptoms with worsening skin conditions such as itch and burning/stinging of the skin may occur upon discontinuation of topical steroids. TSW is a combination of topical steroid addiction, steroid eczema, and red skin syndrome. TSW commonly affects the face and genital region.

TSW remains a challenge for both physicians and patients to diagnose and manage. Currently, there is insufficient data to conclude the definitive cause of this condition. However recent research [4] has indicated that TSW is more commonly seen in adult women who apply mid- or high-potency topical corticosteroids to the face or genital region. Additionally, risks of side effects also occur with inappropriate use of topical steroids such as prolonged periods of topical steroid usage or exposure without tapering or periodic breaks [5].

What is the correct way of applying topical steroids?

You are advised to discuss with your doctor on the frequency and quantity of application of topical steroids that you are prescribed. We also suggest discussing plans on safely tapering off from topical steroid usage to avoid extreme TSW outcomes. 

As a rule of thumb, topical steroids are applied once or twice a day (maximum) in small amounts on the affected skin area or inflamed region. The quantity of topical steroids is measured by fingertip units (FTUs). One FTU of topical steroids is the amount squeezed out of a standard tube covering an adult’s fingertip (just like expressing toothpaste out of a tube). One FTU of medication is adequate to cover 2 flat surface areas of an adult’s palm.

What are the common mistakes and myths about using topical steroids?

• Using too little: tends to occur in overly cautious or steroid-phobic patients or carers of patients. This leads to undertreating of the skin condition which may lead to long-term steroid use. Using too little exposes the patient to an unnecessary risk of developing side effects.
• Using excessively: tends to occur in patients who continuously apply topical steroids in the hope of treating the skin condition faster and avoiding further flare up. This, again, is also not advisable as it increases the risk of a person developing side effects from excessive steroids. You are only advised to use topical steroids as recommended by your doctor.

Topical Steroids: To Use or Not To Use?

As with any medication prescribed, if a medication is administered for the right condition at the right dose, right method, and right frequency, the symptoms will resolve or improve. Every medication has potential side effects. It is pertinent that patients and practitioners take accountability and be proactive in dealing with the prescribed medication. If topical steroids are used judiciously, they are safe and effective in managing certain dermatological conditions

Frequently asked questions

Should I use topical steroids and moisturiser together?

Yes. Using both topical steroids and moisturiser allows for better absorption of the steroid medication and at the same time provides a good seal to the skin barrier with moisturiser to reduce further inflammation. Although there is no hard and fast rule, you can consider applying topical steroids to the affected area. After 15-30min, you can then apply a layer of moisturiser to the skin.

Is there a maximum duration to use topical steroids?

Generally, we suggest following your doctor’s guidance on the duration of topical steroid treatment as every patient’s condition may differ. Every case is subjective to the patient’s condition.

Typically you are advised for a short course (3 days to a week) of a suitable strength or strong topical steroid to manage your skin condition. Once the skin condition is under control, the topical steroid can be tapered to a weaker steroid. This approach involves the use of short bursts of high-strength topical steroids which is clinically proven to be an effective way of managing skin conditions.

In some patients who have recurring flare-ups of skin conditions upon withdrawal of topical steroids, short use of topical steroids (weekend therapy) to prevent flare-ups can be considered. In such a situation, your doctor may advise you to use the steroid cream over the frequent flare-up sites of the skin twice a week to prevent flares. 

Your doctor may want to understand the triggers of your skin condition and tailor your topical treatment regimen based on your triggers and symptoms. Speak to your doctor without further hesitation.

References

1. Mayo Clinic (2022) Dermatitis, Mayo Clinic. Available at: https://www.mayoclinic.org/diseases-conditions/dermatitis-eczema/symptoms-causes/syc-20352380#:~:text=Dermatitis%20is%20a%20general%20term,ooze%2C%20crust%20or%20flake%20off. (Accessed: 06 July 2023). 
2. Whelan, C. (2021) Autoimmune hives: Causes, symptoms, treatments, and more, Healthline. Available at: https://www.healthline.com/health/skin/autoimmune-hives#causes (Accessed: 06 July 2023). 
3. Hewett, L. (2022) TSW: What the eczema community needs to know, National Eczema Association. Available at: https://nationaleczema.org/blog/tsw-need-to-know/#:~:text=The%20potentially%20debilitating%20symptoms%20of,%2C%20fatigue%2C%20depression%20and%20disability. (Accessed: 06 July 2023). 
4. Hajar, T. et al. (2015) A systematic review of topical corticosteroid withdrawal, Journal of the American Academy of Dermatology. Available at: https://www.jaad.org/article/s0190-9622(14)02209-9/fulltext (Accessed: 06 July 2023). 
5. National Eczema Association (2021) Appropriate use of topical corticosteroids, National Eczema Association. Available at: https://nationaleczema.org/appropriate-use-of-topical-corticosteroids/ (Accessed: 06 July 2023). 
6. S, D.A. (2017) Use of topical corticosteroids in dermatology: An evidence-based approach, Indian Journal of Dermatology. Available at: https://pubmed.ncbi.nlm.nih.gov/28584365/ (Accessed: 06 July 2023).