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Use of Topical Corticosteroids

• Topical corticosteroid preparations are used in the treatment of inflammatory conditions of the skin other than those due to an infection. They are not curative, and should be backed up with other measures, in particular irritant avoidance and regular emollients.
• Topical steroids should be applied thinly, once or twice daily.  When applying along with an emollient, it doesn’t matter which agent is applied first, although ideally there should be a 15-30 minute gap between the two applications.
• They should not be used indiscriminately in pruritus, urticaria, or in undiagnosed rashes. They are contraindicated in rosacea, and care should be taken with regular review when treating any facial eruption where the diagnosis is unclear.  Potent steroids should only be used in psoriasis (other than scalp) under specialist supervision due to the risk of provoking a severe pustular flare.  Potent steroids can be used in recalcitrant conditions such as palmoplantar pustulosis, lichen simplex and nodular prurigo, as long as such patients are reviewed regularly to ensure treatment is appropriate.
• Choice of steroid strength will depend on the nature of the condition being treated, the age of the patient and the site of disease, the aim being to use the weakest preparation that will suppress the inflammation.  Particular care should be taken when treating children (especially under wet wrap dressings), faces and flexures.  It is reasonable to supply two strengths for patients with chronic conditions, one to be used for maintenance and a stronger one for short-term use during flare-ups.
• Compound preparations, which usually contain antimicrobial agents, are useful where there is overt secondary infection. Their use otherwise is debatable, although they are often used where there may be a microbial component present such as in flexures. Those that contain fusidic acid should only be used for short periods of time (up to 7 days) to reduce the likelihood of developing bacterial resistance.
• Prolonged use of potent steroids will lead to skin atrophy with easy bruising and striae formation and can suppress the pituitary-adrenal axis. 
• Use on any strength of topical steroid on the face may cause a rosacea-like papular eruption (perioral dermatitis).   
• Care should be taken with topical steroid use around the eyes because of the possibility of increased ocular pressure and cataract formation.  In general, only mildly potent steroids should be used for as short a time as possible.

Fingertip units can also be helpful when determining prescription quantities. One fingertip unit (the amount, approximately 0.5g, which covers the distal phalanx of the forefinger when squeezed out of the tube) is sufficient to cover the area of both hands in an adult.

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