How do the various topical steroids differ?

There are more than 30 different topical steroid products. They vary greatly in terms of the strength of their effect (their potency), and can generally be divided up into four groups:

• Low-potency steroids, e.g. hydrocortisone and prednisolone
• Moderate-potency steroids like prednicarbate, methylprednisolone and triamcinolone
• High-potency steroids such as betamethasone and mometasone
• Ultra-high-potency steroids, such as clobetasol

How well a steroid medication works will depend on its active ingredient (the drug in it) and various other factors, including the following:

• The dosage used
• The area of skin that it is applied to: Thinner skin absorbs more steroids than thicker skin does. So the skin on the palms of your hands and soles of your feet absorbs less of the steroid drug than the skin on your face and scalp does, for example. The skin on your eyelids and genitals is particularly sensitive.
• The type of product: Steroid ointments are stronger than steroid creams or lotions. This is because steroids are more easily absorbed by the skin when applied as an ointment.
• How it is applied: Topical steroids work better when applied to wet skin – for instance after getting out of the bath – than when applied to dry skin. The effect is stronger if the skin is covered up with a bandage or wet wrap after the steroid medication is applied. This increases the amount of steroids that are absorbed.

You can only get steroid medications if you have a prescription from a doctor. Low-dose hydrocortisone is an exception here. Ointments or creams containing low doses of hydrocortisone are available from pharmacies even without a prescription. It’s best to talk to your doctor about which topical steroid to use and how to apply it.

Which topical steroid is most suitable?

The choice of topical steroid will depend on the person’s age, how severe their eczema is, and which area of their body is affected. Low-potency and moderate-potency steroids are usually enough to keep eczema at bay. Generally speaking:

• Topical steroids of low to moderate potency are particularly suitable for treating parts of the body where the skin is thin. These include the face, the back of the knees, the insides of the elbows, the groin area and the armpits.
• High-potency and ultra-high-potency steroids are used for the treatment of severe rashes on the palms of the hands and soles of the feet, or for the treatment of eczema on very thick skin.
• High-potency and ultra-high-potency steroids shouldn’t be used on rashes that cover a large area of skin.
• Very sensitive areas such as your neck or genitals should only be treated with low-potency steroids.

It is also possible to switch between products of different strengths. For example, some doctors recommend starting treatment with a high-potency steroid in order to get the flare-up under control as quickly as possible, and then switching to a weaker steroid after a few days. Others prefer to start with a low-potency steroid and only change to a stronger one if the first medication doesn’t work well enough. It’s best to talk to your doctor about the most suitable strategy for you.

How are steroids used?

Steroid ointments or creams are applied to the affected areas of skin one or two times a day – for instance, in the morning and/or afternoon. This treatment is continued until the inflammation has gone away. It can last anywhere between a few days and six weeks. This will depend on the strength of the steroid and the affected areas of skin. Steroid medication generally shouldn’t be applied to sensitive areas of the body for longer than a few days.

It is important to continue using moisturizing products on the skin during treatment with steroids. Doctors recommend waiting about 15 minutes between applying a topical steroid and applying the moisturizing product. This allows the steroid to be absorbed properly. According to current knowledge, it doesn’t matter which order you apply them in.

If the eczema is severe, you can apply the topical steroid first and then cover the affected area with a wet wrap in order to increase the effect of the medication. But there is no good research on the benefits and drawbacks of this approach. A number of studies have shown that the risk of side effects is higher if you use wet wraps after applying topical steroids. The possible side effects include inflamed hair follicles and skin infections. Using wet wraps can also cause greater amounts of steroids to enter your body. So it’s important to talk to a doctor about whether to use this approach before trying it out.

The right amount

How much steroid ointment or cream you should use will depend on how big the affected area of skin is. A unit known as the “fingertip unit” (FTU) is used to describe the amount needed. 1 FTU is the amount of ointment or cream that is squeezed out of a tube along the last section of an adult’s finger (see illustration). This is about 0.5 grams.

1 fingertip unit (1 FTU)

Depending on the area of skin, the following amounts (in FTUs) are recommended in children:

Depending on the area of skin, the following amounts (in FTUs) are recommended in adults:

What are the side effects?

People are often wary of using steroids because they have heard a lot of bad things about the side effects. In the past, many people who were treated with steroids experienced side effects. This is because steroid medications were often used for too long, too often, and in too high doses.

The main worry is usually that the steroids will make the skin thinner. But studies comparing different treatments haven’t found any proof that the skin becomes permanently thinner if steroids are used correctly, and only when needed. In the largest and longest study on the use of steroid medication, fewer than 1 out of 1,000 children showed signs of noticeable skin thinning over a time period of five years.

Other possible side effects include small changes in pigmentation (white spots), and temporary blisters. This is the medical term for small dilated capillaries that look a bit like spider webs on the skin.

Avoiding side effects

There are many things you can do to avoid side effects:

• Choose a topical steroid that’s suitable for the severity of the disease and the affected area of skin.
• For longer-term treatment, it is best to use a topical steroid that is as strong as necessary and as weak as possible.
• Only apply a thin layer of the steroid once a day. That is usually enough. According to current research, steroid creams or ointments aren’t more effective when used twice a day – or at least the stronger products aren’t.
• Treat the skin with the topical steroid until the flare-up is over (the skin stops itching and the inflammation has gone away). If you stop the treatment too soon, the rash might return and have to be treated again. Then you might end up using more steroid medication overall than if you had continued using it for long enough in the first place.

Some people are afraid of severe side effects that affect the whole body. But when steroids are applied to the skin in the form of ointments or creams, a far smaller amount of the drug enters the body than when swallowed in the form of tablets. So if topical steroids are used properly, the risk of severe side effects is very small.

Can steroids be used in pregnancy too?

Applying steroids to the outside of the body is considered to be safe in pregnancy. It is generally safe while breastfeeding too. But it's important to make sure that the baby doesn't come into contact with the medication – for instance, when using it to treat skin on the breast.

Scientific studies have confirmed that it is safe to use steroid creams and ointments in pregnancy. A group of researchers analyzed the data of a large number of women and their babies. There was no link between the use of low- to moderate-potency topical steroids and complications during pregnancy. The researchers looked at things like defects at birth, birth weight, and which week of pregnancy the baby was born in. There was weak evidence that using high-potency to ultra-high-potency topical steroids could lead to a lower birth weight – particularly if the steroids were used in quite large amounts. But they didn't find any links to other complications.

Preventing flare-ups through intermittent use

People who have moderate to severe eczema with frequent flare-ups may benefit from using topical steroids intermittently on only two days per week, while still using moisturizing products every day on the usually affected areas of skin. Sometimes referred to as "proactive therapy," this approach can significantly reduce the frequency of flare-ups. The steroid cream can either be applied on two consecutive days (e.g. as a "weekend therapy") or with a break between the two days – for instance, on Mondays and Thursdays.

Because eczema sometimes gets better over time on its own, it's a good idea to stop using the steroid after a while in order to see whether you still need it.

When can pimecrolimus and tacrolimus be used?

Two other medications have been approved in Germany for the treatment of eczema: Pimecrolimus (trade name: Elidel) and tacrolimus (trade names: Protopic, Prograf, Advagraf). These both belong to a group of drugs called calcineurin inhibitors. Also known as immunomodulators, they inhibit specific substances that play a role in inflammation.

A thin layer of pimecrolimus or tacrolimus is applied to inflamed areas of skin twice a day. Pimecrolimus has been approved in the form of a 1% cream. Tacrolimus comes in two forms: a 0.03% ointment and a 0.1% ointment.

Pimecrolimus has been approved for the treatment of mild to moderate eczema, and tacrolimus has been approved for the treatment of moderate to severe eczema. They can only be used in certain situations. For instance, they can be prescribed

• if steroids haven't led to a big enough improvement.
• for the treatment of particularly sensitive areas such as the genitals or face, and especially the eyelids.
• if steroids aren't well tolerated.

Creams and ointments with pimecrolimus and 0.03% tacrolimus can be used in children aged two and over, as well as in teenagers and adults. Those with 0.1% tacrolimus can only be prescribed for people aged 16 and over.

Calcineurin inhibitors can also be used to prevent further flare-ups. This involves applying them to the usually affected areas of skin on two days per week (once on each day). You should wait a few days between applications.

Do pimecrolimus and tacrolimus have any advantages over steroids?

Research has shown that pimecrolimus and tacrolimus can relieve eczema flare-ups. But they aren't more effective than steroid creams of similar strength, and are even somewhat more likely to cause side effects. Burning, redness and itching may occur, particularly in the first few days of treatment.

A large, long-term study involving more than 2,400 children found that pimecrolimus also increased the risk of skin infections and bronchitis. This study compared pimecrolimus with low- to moderate-potency topical steroids. There is no proof that pimecrolimus and tacrolimus are less likely to make the skin thinner than steroids are.

Sources

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