creation date: 2025-08-06 03:00
tags: Pharmacology
Topical Corticosteroids
Background
Mechanism of action
Topical steroids have anti-inflammatory, anti-mitotic, and immunosuppressive properties.
Anti-inflammatory effects include:
- Vasoconstriction - reduces delivery of inflammatory mediators
- Inhibition of phospholipase A2 release - which reduces prostaglandins and leukotrienes
- Inhibition of DNA and inflammatory transcription factors - decrease expression of pro-inflammatory genes
Anti-mitotic effects are secondary to increase in lipocortin (endogenous glucocorticoid-regulated protein), which inhibit cell proliferation and collagen synthesis. These effects are relevant to psoriasis.
Immunosuppressive effects involve inhibiting humoral factors in the inflammatory response and suppressing immune cell maturation, differentiation, and proliferation.
Forms of administration
Ointments (ung):
- Most effective due to occlusive nature (more potent)
- More effective in dry, scaly, or hyperkeratinized skin areas, palms, soles
- Avoid in hairy areas due to folliculitis
Creams (crm): - Cosmetically more appealing due to absence of residue
- Suitable for acute/wet lesions or intertriginous areas
Lotions (lot): - Less occlusive than creams
- Useful for axilla, foot, groin, and hairy areas
Gels: - Similar to lotions, non-occlusive, non-greasy
- Suitable for scalp or hairy areas
Foams: - Good for hairy areas
- Alcohol bases may irritate, price usually higher
Quantity-dosage (adult)
1 fingertip unit (FTU) is ~0.5 g. 1g of cream covers ~100cm2 of area (ointments slightly less required, ~5-10% less).
| Area | Single application | BID x 7d |
|---|---|---|
| 1 hand; both elbows; face; genital | 1 g | 15g |
| 1 arm; head; face and neck | 2 g | 20-30 g |
| Front or back of trunk | 3 g | 30-45 g |
| 1 leg | 4 g | 45-60 g |
| Whole body | 30-60 g | 500-1000 g |
Adverse effects
With prolonged use:
- Skin atrophy
- Acne
- Telangiectasia
- Irreversible striae
Eyelid use: - Glaucoma and cataracts (rare)
High potency: - Adrenal suppression (rare)
- Withdrawal reactions
- Risk of osteoporosis with cumulative doses >10000 g
- Pregnancy - risk of IUGR, orofacial cleft
Potency Levels
Note: bolded options are commonly used reference product for the potency
Class I - ultra-high potency
Characteristics
- Typically reserved for resistant conditions
- Suitable for short term intermittent use in severe cases
- Limit to daily-BID due to high risk of serious side effects (local and systemic)
- Duration should be ≤2-4 weeks followed by less potency option
- Avoid use on large areas, thin skin areas, skin folds, face
- Caution in young children/infants
Options
- Clobetasol propionate 0.05% (Dermovate) ung/crm/lot/foam
- Betamethasone dipropionate glycol 0.05% (Topilene Glycol) ung/crm/lot
- Betamethasone dipropionate 0.05% + salicylic acid 3% (Diprosalic) ung/lot
- Halobetasol propionate 0.05% (Ultravate) ung/crm
- Halobetasol 0.01%/Tazarotene 0.045% lot
Class II - high potency
Characteristics
- Same as class I
Options
- Betamethosone dipropionate 0.05% (Diprosone, Topisone) ung
- Amcinonide 0.1% (Cyclocort) ung
- Desoximetasone 0.25% (Topicort) ung/crm
- Desoximetasone 0.05% (Topicort) gel
- Fluocinonide 0.05% (Lidex, Lyderm) ung/crm/gel
- Betamethosone diproprionate 0.05% + calcipotriol 50mcg/g (Dovobet) ung/gel - for psoriasis
- Mometasone furoate 0.1% (Elocom, ~class III) ung
Class III - medium- to high-potency
Characteristics
- Same as class I
Options
- Betamethasone valerate 0.1% (Betaderm, Celestoderm) ung/foam
- Betamethasone diproprionate 0.05% (Diprosone, Lotriderm) crm/lot
- Betamethasone diproprionate + calcipotriol (Enstilar) foam
- Amcinonide 0.1% (Cyclocort) crm/lot
- Betamethasone valerate (Betaflam) patch
Class IV - medium potency
Characteristics
- Suitable for intermittent long-term use or chronic use in thick skin areas
- Avoid on thin skin areas
- Caution if used on face, intertriginous areas (high risk of adverse effect)
Options
- Triamcinolone acetonide 0.1% (Aristocort R, Oracort Dental) ung/crm
- Fluocinolone acetonide 0.025% (Synalar) ung/topical oil
- Hydrocortisone valerate 0.2% (Hydroval) ung
- Beclomethasone dipropionate 0.025% (Propaderm) crm
- Clobetasone butyrate 0.05% (Spectro Eczema Care, OTC) crm
- Desoximetasone 0.05% (Topicort Mild) crm
- Mometasone furoate 0.1% (Elocom) crm/lot
Class V - medium potency
Characteristics
- Same as class IV
Options
- Betamethasone valerate 0.05% (Betaderm, Celestoderm) ung/crm/lot
- Betamethasone valerate 0.1% crm/lot
- Hydrocortisone valerate 0.2% (Hydroval) crm
- Prednicarbate 0.1% (Dermatop) crm
Class VI - low-potency
Characteristics
- Suitable for maintenance following initial control using higher potency options
- Can use more frequently (BID-QID)
- Safer for infants, children, elderly, or large/higher risk areas
Options
- Desonide 0.05% ung/crm
- Hydrocortisone/Urea 1%/10% (Dermaflex HC) lot
Class VII - least-potent
Characteristics
- Same as class VI
Options
- Hydrocortisone 2.5% crm
- Hydrocortisone 0.05-1% (Cortoderm, Hyderm, OTC) ung/crm