Steroid Creams: Strengths, How Much to Use and How to Use Them Safely

Steroid creams are among the most effective treatments for eczema and other inflamed skin conditions. Yet many people use too little, for too short a time, because they are worried about side effects.

Imagine your child’s eczema flaring, red and cracked behind the knees. You are prescribed a steroid cream but are afraid it will thin their skin, so you dab on a tiny amount once and stop. The eczema gets worse.

What topical steroids do

Topical corticosteroids reduce inflammation, redness, swelling and itching in the skin. They are used for eczema (dermatitis), psoriasis, allergic skin reactions, insect bite reactions and some other inflammatory skin conditions. They do not treat infections and should not be used on infected skin unless combined with an anti-infective treatment.

Strength categories

• Mild: for example hydrocortisone 1%; used for the face, folds and children
• Moderate: for example clobetasone butyrate
• Potent: for example betamethasone valerate and mometasone
• Very potent: for example clobetasol propionate; usually specialist or short-term use
• Strength classifications differ between countries; ask your pharmacist where your product fits

How much to use: fingertip units

A fingertip unit (FTU) is the amount of cream or ointment squeezed from a standard tube along an adult’s index finger, from the tip to the first crease. One FTU covers an area about the size of two adult palms.,Using enough matters. Too little cream can mean the treatment does not work, so the skin stays inflamed for longer. Your healthcare provider or pharmacist can tell you how many fingertip units to use for each area.

How to apply

1. Wash and dry your hands
2. Apply a thin layer to the inflamed skin only, usually once or twice a day as directed
3. Gently smooth it in the direction of hair growth
4. Wash your hands afterwards, unless treating the hands
5. If you also use a moisturiser (emollient), leave about 20 to 30 minutes between applying the moisturiser and the steroid

Cream or ointment?

Ointments are greasier and more moisturising, which suits dry, thickened skin. Creams are lighter and better for moist or weeping areas and for use during the day. Lotions and gels suit hairy areas such as the scalp.

Sensitive areas

Skin on the face, eyelids, genitals and body folds (armpits, groin, under the breasts) is thinner and absorbs steroids more easily. Usually only mild steroids are used in these areas, for short periods, unless a specialist advises otherwise. Never use a potent steroid on the face without medical advice.

Side effects

Used correctly, topical steroids are safe for most people. With prolonged use of stronger steroids, especially on thin skin, side effects can include skin thinning, stretch marks, easy bruising, visible blood vessels, changes in skin colour and acne-like spots or rosacea on the face.,Very rarely, using large amounts of very potent steroids over large areas for long periods can affect the whole body. Your healthcare provider will balance the benefits against the risks.

Steroid phobia and topical steroid withdrawal

Many people and parents are frightened of steroid creams, often because of stories online. This fear can lead to under-treatment, which leaves eczema uncontrolled, itchy and more likely to become infected. When used as directed, the benefits usually far outweigh the risks.,Some people report a severe skin reaction after stopping long-term use of steroid creams, often called topical steroid withdrawal. It is still being studied. If you are worried, talk to your healthcare provider or a dermatologist about a safe plan rather than stopping suddenly on your own.

Children

Steroid creams can be used safely in children when needed, usually starting with mild strengths. Parents should be shown how much to use and where. Many children with eczema use a “weekend therapy” or proactive approach, applying steroid twice a week to areas that often flare, which can reduce flares.

When to stop or seek advice

• When the skin has cleared, usually stop or step down as advised
• If there is no improvement after a week or two
• If the skin becomes infected: weeping, crusting, yellow, painful or with fever
• If you need steroids continuously for months
• If you notice skin thinning or other side effects

Frequently asked questions

Can I buy steroid creams over the counter?

Mild hydrocortisone is available from pharmacies in many countries, with restrictions on where and how long it can be used.

Should I keep using moisturiser?

Yes. Emollients are the foundation of eczema treatment and should be used every day, even when the skin is clear.

Is it safe in pregnancy?

Mild to moderate steroid creams are commonly used in pregnancy. Ask your healthcare provider.

But I am scared of thinning my skin

Skin thinning is uncommon when steroids are used at the right strength, in the right amount and for the right time. Ask for a clear plan so you feel confident.

Related: Eczema in babies and children · Psoriasis

Sources: British Association of Dermatologists, National Eczema Society, National Institute for Health and Care Excellence, American Academy of Dermatology, US Food and Drug Administration.