Low-potency steroids are the safest agents for long-term use, on large surface areas, on the face or areas of the body with thinner skin, and on children. More potent agents are beneficial for severe diseases and for areas of the body where the skin is thicker, such as the palms and bottoms of the feet. High- and ultra-high-potency steroids should not be used on the face, groin, axilla, or under occlusion, except in rare situations and for short durations.
Once-or twice-daily application is recommended for most preparations. Chronic application of topical steroids can induce tolerance and tachyphylaxis. Ultra-high-potency steroids should not be used for more than three weeks continuously. This intermittent schedule can be repeated chronically or until the condition resolves. Side effects are rare when low- to high-potency steroids are used for three months or less, except in intertriginous areas, on the face and neck, and under occlusion.
The amount of steroid the patient should apply to a particular area can be determined by using the fingertip unit method. Table 3 describes the number of fingertip units needed to cover specific areas of the body. The amount dispensed and applied should be considered carefully because too little steroid can lead to a poor response, and too much can increase side effects.
Prolonged use of topical corticosteroids may cause side effects Table 4 To reduce the risk, the least potent steroid should be used for the shortest time, while still maintaining effectiveness. The most common side effect of topical corticosteroid use is skin atrophy. All topical steroids can induce atrophy, but higher potency steroids, occlusion, thinner skin, and older patient age increase the risk. The face, the backs of the hands, and intertriginous areas are particularly susceptible.
Resolution often occurs after discontinuing use of these agents, but it may take months. Concurrent use of topical tretinoin Retin-A 0. Topical steroids can also induce rosacea, which may include the eruption of erythema, papules, and pustules.
Steroid-induced rosacea occurs when a facial rash is treated with low-potency topical steroids that produce resolution of the lesions. If the symptoms recur and steroid potency is gradually increased, the rosacea may become refractory to further treatment, making it necessary to discontinue the steroid. This may then induce a severe rebound erythema and pustule outbreak, which may be treated with a day course of tetracycline mg four times daily or erythromycin mg four times daily.
For severe rebound symptoms, the slow tapering of low-potency topical steroids and use of cool, wet compresses on the affected area may also help. The normal presentation of superficial infections can be altered when topical corticosteroids are inappropriately used to treat bacterial or fungal infections.
Steroids interfere with the natural course of inflammation, potentially allowing infections to spread more rapidly. The application of high-potency steroids can induce a deep-tissue tinea infection known as a Majocchi granuloma. Easy bruising. Increased fragility. Stellate pseudoscars. Steroid atrophy. Aggravation of cutaneous infection. Granuloma gluteale infantum.
Masked infection tinea incognito. Secondary infections. Contact dermatitis. Delayed wound healing. Hypertrichosis hirsutism. Perioral dermatitis. Reactivation of Kaposi sarcoma. Rebound flare. Steroid-induced acne.
Steroid-induced rosacea. Ocular hypertension. Cushing disease. Hypothalamic-pituitary-adrenal suppression. Aseptic necrosis of the femoral head. Decreased growth rate. Peripheral edema. Adverse effects of topical glucocorticosteroids. J Am Acad Dermatol. This tinea folliculitis requires oral antifungal therapy. Combinations of antifungal agents and corticosteroids should be avoided to reduce the risk of severe, persistent, or recurrent tinea infections.
Topical applications of corticosteroids can also result in hypopigmentation. This is more apparent with darker skin tones, but can happen in all skin types. Repigmentation often occurs after discontinuing steroid use. Steroids can induce a contact dermatitis in a minority of patients, but many cases result from the presence of preservatives, lanolin, or other components of the vehicle.
Non-fluorinated steroids e. Topically applied high- and ultra-high-potency corticosteroids can be absorbed well enough to cause systemic side effects. Hypothalamic-pituitary-adrenal suppression, glaucoma, septic necrosis of the femoral head, hyperglycemia, hypertension, and other systemic side effects have been reported.
According to a postmarketing safety review, the most frequently reported side effects were local irritation 66 percent , skin discoloration 15 percent , and striae or skin atrophy 15 percent. Topical steroids can induce birth defects in animals when used in large amounts, under occlusion, or for long duration.
Food and Drug Administration as pregnancy category C. It is unclear whether topical steroids are excreted in breast milk; as a precaution, application of topical steroids to the breasts should be done immediately following nursing to allow as much time as possible before the next feeding.
Children often require a shorter duration of treatment and a lower potency steroid. Already a member or subscriber? Log in. At the time the article was written, Dr. He received his doctorate of pharmacy from the Nesbitt College of Pharmacy and Nursing and completed residency training and a faculty development fellowship at the University of Pittsburgh Pa.
Margaret Family Medicine Residency Program. Address correspondence to Jonathan D. South St. Reprints are not available from the authors. Interventions for chronic palmoplantar pustulosis. Cochrane Database Syst Rev. A double-blind randomized trial of 0. Arch Dermatol. Vitiligo: a retrospective comparative analysis of treatment modalities in patients.
J Dermatol. Vulvar lichen sclerosus: effect of long-term topical application of a potent steroid on the course of the disease. The treatment of mild pemphigus vulgaris and pemphigus foliaceus with a topical corticosteroid. Br J Dermatol. A comparison of oral and topical corticosteroids in patients with bullous pemphigoid. N Engl J Med. Efficacy and safety of a new clobetasol propionate 0. J Eur Acad Dermatol Venereol. Randomized double-blind placebo-controlled trial in the treatment of alopecia areata with 0.
An open-label study of the safety and efficacy of limited application of fluticasone propionate ointment, 0. Int J Dermatol. Intermittent dosing of fluticasone propionate cream for reducing the risk of relapse in atopic dermatitis patients. Effect of topical steroid on non-retractile prepubertal foreskin by a prospective, randomized, double-blind study. Scand J Urol Nephrol. An month follow-up study after randomized treatment of phimosis in boys with topical steroid versus placebo.
Topical corticosteroid therapy for acute radiation dermatitis: a prospective, randomized, double-blind study. Prophylactic beclamethasone spray to the skin during postoperative radiotherapy of carcinoma breast: a prospective randomized study. Indian J Cancer.
Treatment of chronic idiopathic urticaria with topical steroids. An open trial. Acta Derm Venereol. Infantile acropustulosis revisited: history of scabies and response to topical corticosteroids. Pediatr Dermatol. Betamethasone cream for the treatment of pre-pubertal labial adhesions. J Pediatr Adolesc Gynecol. Use of topical corticosteroid pretreatment to reduce the incidence and severity of skin reactions associated with testosterone transdermal therapy.
Clin Ther. Pariser DM. Topical steroids: a guide for use in the elderly patient. Guidelines of care for the use of topical glucocorticosteroids. Goa KL. Clinical pharmacology and pharmacokinetic properties of topically applied corticosteroids. A review. McKenzie AW. Comparison of steroids by vasoconstriction. Facts and Comparisons 4. Accessed February 10, Olsen EA. A double-blind controlled comparison of generic and trade-name topical steroids using the vasoconstriction assay.
Topical steroids: dosing forms and general considerations. Stretch marks usually occur on the upper inner thighs, under the arms, and in the elbow and knee creases. It should be noted that preteens and teenagers who have never used corticosteroids can also get stretch marks.
Permanent skin atrophy from topical corticosteroids is now extremely uncommon when the treatment is used properly. In the past, recommendations did not specify the amount, frequency and duration to apply topical corticosteroids. We now know that these medications are safest when used intermittently, in an appropriate quantity, and for an appropriate length of time. Many patients with under-treated eczema have the opposite of skin thinning, and actually develop thickening, and sometimes darkening of the skin changes known as lichenification.
Frequent and prolonged application of a topical corticosteroid to the eyelids can cause glaucoma and even cataracts. Topical corticosteroids can occasionally cause tiny pink bumps and acne, especially when used on the face and around the mouth.
On the body, greasy corticosteroid ointments can rarely cause redness around hair follicles, sometimes with a pus bump centered in the follicle folliculitis. The risk of adrenal suppression is highest with high potency Class corticosteroids. Infants and young children have a higher ratio of body surface area compared to their weight, so they are more susceptible to corticosteroid absorption. If a child is given corticosteroids by mouth, in large doses or over a long term, prolonged adrenal suppression can be associated with growth suppression and weakened immune responses.
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|Topical steroids for acne||Intermittent dosing of fluticasone propionate cream for reducing the risk of relapse in atopic dermatitis patients. Read about other types of corticosteroidsincluding tablets, capsules, inhalers and injected corticosteroids. To reduce the risk, the least potent steroid should be used for the shortest time, while still maintaining effectiveness. Infantile acropustulosis revisited: history of scabies and response to topical corticosteroids. Repigmentation often occurs after discontinuing steroid use. This is a useful but imperfect method for predicting the clinical effectiveness of steroids.|
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Most people who use topical steroids as directed do not get topical steroid withdrawal. Risk factors for developing topical steroid withdrawal include using mid- or high-potency steroids, using topical steroids more frequently or for a longer duration than recommended and using topical steroids on the face or groin region.
Most cases of topical steroid withdrawal have been described in people who use mid- or high-potency topical steroids. For example, creams and ointments tend to be stronger than lotions and solutions. Examples of mid- and high-potency topical steroids include triamcinolone 0. This may cause topical steroid withdrawal. High-potency topical steroids are typically not to be used more than once daily, and for no longer than three weeks at a time. In some cases, your physician may recommend using a mid- or high-potency topical steroid intermittently, such as twice a week as maintenance therapy.
In addition, most physicians will recommend tapering the topical steroid once the skin condition has resolved. Most people who develop topical steroid withdrawal use topical steroids daily and for more than 12 months. Using topical steroids on the face or groin regions increases the risk of developing topical steroid withdrawal.
This is because the skin on the face and groin regions is thinner and absorbs topical steroids more easily, predisposing the individual to develop topical steroid withdrawal in those areas. Treatment for topical steroid withdrawal involves discontinuing the use of topical steroid medications and managing the symptoms of the withdrawal. Specific treatment options include:.
In most cases of topical steroid withdrawal, the first step in treatment is to discontinue the use of topical steroid medications. Some physicians may recommend tapering the topical steroid slowly, due to concern that stopping the topical steroid suddenly may worsen the withdrawal symptoms. However, other physicians may recommend stopping the topical steroid suddenly once withdrawal symptoms develop since some studies show no difference between stopping suddenly and stopping gradually.
Some physicians may recommend applying ice or cool compresses to the skin to alleviate stinging, burning, or itching. People with steroid withdrawal syndrome who experience significant itching may benefit from antihistamine medications , which prevent the body from releasing substances that contribute to the itching.
The doctor may recommend one of two types of antihistamines. Some people with steroid withdrawal syndrome may benefit from a course of certain antibiotic medications, such as tetracycline, doxycycline, or erythromycin. These antibiotic medications have anti-inflammatory effects as well, and therefore may be helpful in controlling symptoms.
Antibiotic medications are more often used for people with the papulopustular type of rash. Some physicians may recommend that people with topical steroid withdrawal complete a short course of oral steroid medications, such as prednisolone. Topical steroid withdrawal is only due to the excess use of topical steroids, so a course of oral steroids would not worsen the symptoms and may help by reducing inflammation throughout the body.
Because steroid withdrawal syndrome can cause a fair amount of distress due to the symptoms and the appearance of the rash, some people with steroid withdrawal syndrome may benefit from psychological support such as counseling. If you develop any symptoms of topical steroid withdrawal after using topical steroids, you should see your physician. He or she can determine if your symptoms such as skin redness, swelling, burning, or itching, are in fact due to topical steroid withdrawal.
Self-diagnose with our free Buoy Assistant if you answer yes on any of these questions. Liu received his medical degree from the University of Pennsylvania Perelman School of Medicine and is pursuing a career in ophthalmology. He has published research in multiple ophthalmology and healthcare journals and has received awards from Research to Prevent Blindness.
In his free time, he enjoys running, biking, and spending time with his friends and family. Questions may relate to diseases, illnesses, or conditions you may have or that may run in your family. Your answers will help us provide you with medical information and identify services that may be relevant to your health.
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Nav Close Icon. Nav Open Icon. Health articles Chevron Icon. Featured topics. Symptom checker. Editorial standards. Who we serve Chevron Icon. Brokers and Consultants. Solutions Chevron Icon. Care Navigation. Sections Icon. What is topical steroid withdrawal? When to see a doctor. Skin Conditions. Buoy Chat Icon. Symptom Checker. Verified By Experts Icon. Verified by experts 7 min read.
No Ads. Tom Liu, MD. Ophthalmology Resident, University of Pennsylvania. Jeffrey M. Last updated August 27, Heart Icon. Speech Bubble Icon. Share Icon. Facebook Icon. LinkedIn Icon. Pinterest Icon. Pocket Icon. Share Link Icon. Copied to clipboard. Table of Contents. Topical steroid withdrawal questionnaire Use our free symptom checker to find out if you have topical steroid withdrawal. Topical steroid withdrawal symptoms Topical steroid withdrawal symptoms usually develop within days to weeks after stopping a topical steroid medication.
Erythematoedematous rash People with topical steroid withdrawal who develop the erythematoedematous form of rash will experience the following. Redness and swelling of the skin: This will be at the site of topical steroid application. Skin that is scaly or peeling Red bumps may or may not be present Defined rash border: In some people who develop this type of rash on the face, there may be a sharp cutoff between the red and normal-appearing parts of the skin, with sparing of the nose and ears.
Papulopustular rash People with topical steroid withdrawal who develop the papulopustular form of rash will experience the following. Redness with prominent red bumps and pus-filled bumps: These will appear over the area of topical steroid application. Less prominent swelling No skin peeling Other symptoms Other symptoms associated with topical steroid withdrawal include the following. Burning and stinging of the skin: Most people experience a burning and stinging sensation over the skin where the topical steroid was applied.
This is usually more prominent in the erythematoedematous type of rash than in the papulopustular type of rash. In some cases, the skin may feel outright painful. The burning and stinging may be exacerbated with exposure to heat or the sun. Itchy skin: Some people with topical steroid withdrawal may also experience itching of the skin where topical steroids were applied.
Itching usually follows a period of burning and stinging and occurs once the redness starts to fade. The itching may be severe enough to interfere with sleep. Facial hot flashes: Some people who develop topical steroid withdrawal on the face may experience episodes of hot flashes. When these episodes occur, their face will flush red and may feel warm. Topical steroid withdrawal causes Topical steroid withdrawal usually occurs in adults older than 18 years old and has been reported more frequently in women.
Using mid- or high-potency topical steroids Most cases of topical steroid withdrawal have been described in people who use mid- or high-potency topical steroids. Using topical steroids more frequently or for a longer duration than recommended This may cause topical steroid withdrawal. Using topical steroids on the face or groin regions Using topical steroids on the face or groin regions increases the risk of developing topical steroid withdrawal.
Treatment options and prevention Treatment for topical steroid withdrawal involves discontinuing the use of topical steroid medications and managing the symptoms of the withdrawal. Specific treatment options include: Discontinue the use of topical steroid medications In most cases of topical steroid withdrawal, the first step in treatment is to discontinue the use of topical steroid medications.
Apply ice or cool compresses Some physicians may recommend applying ice or cool compresses to the skin to alleviate stinging, burning, or itching. These topical steroids are considered moderately potent:. These topical steroids are considered somewhat potent:. These topical steroids are considered mild:.
These topical steroids are considered the least potent:. Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life. J Clin Med. Gabros S, Zito PM. Topical Corticosteroids. StatPearls Publishing.
Updated January 10, Mechanisms of action of topical corticosteroids in psoriasis. Int J Endocrinol. Humbert P, Guichard A. The topical corticosteroid classification called into question: towards a new approach. Exp Dermatol. Side-effects of topical steroids: A long overdue revisit. Indian Dermatol Online J. Rathi SK, D'souza P. Rational and ethical use of topical corticosteroids based on safety and efficacy. Indian J Dermatol. Table of Contents View All.
Table of Contents. Mechanism of Action. Classification by Strength. Treatment Considerations. Steroid Classes. Was this page helpful? Thanks for your feedback! Sign Up. What are your concerns? Article Sources.