Originally published on Substack.
Topical steroids get a bad rap. They are unjustly villainized. Why do I say that?
Because when used wisely and appropriately, they are the most effective, most economical and safest treatment that we have for eczema. Put another way, they work, are cheap and have very few side effects. Again, the key to this powerful statement is, “when used wisely and appropriately.”
Topical steroids are the fire extinguishers that put the fire out. They get the eczema flare under control in short order (typically a few days). Itch improves and normalcy begins to be restored.
There are seven groups of topical steroids with group 1 being the most potent and group 7, the least potent. It is extremely important that the appropriate topical steroid is chosen for the flare.
Higher potency topical steroids are typically used on thick areas of skin such as the hands and feet while lower potency steroids work optimally on thinner areas of skin such as neck, face and groin. Medium potency steroids work fairly well on all other areas including the trunk, arms and legs.
Ideally you want the lowest potency steroid that will control the flare on that particular part of the body. However, this can be a double edged sword and direction from an experienced physician can make a world of difference.
For example, a low potency steroid applied to a flare on the hands is often like trying to control a forest fire with a garden hose. It won’t do much, the flare will persist and may even spread. On the contrary, a high potency steroid applied to the face is like trying to drink from a fire hydrant. It is way too powerful and has the potential to do more damage than improving the flare.
Cost is typically not an issue when it comes to topical steroids whereas it is often a problem with newer non-steroidal topical creams for eczema. For example, the 2 most frequent topical steroids that I prescribe average about $10 for an 80 gram tube.
Topical steroids, unlike oral or injectable steroids, are minimally absorbed by your body. This is especially the case if used on a small area of the body. Thus, they are very unlikely to cause the side effects that you may associate with steroids including immune system suppression, growth stunting/bone loss, eye and kidney damage, etc. Oral or injectable steroids can cause these unwanted side effects but should only be given in the most severe cases of eczema. Personally, I have only prescribed oral steroids a few times in my outpatient clinics for very difficult eczema cases that I watched closely. Otherwise they are avoided like the plague by specialists due to the potential for worsening or rebound eczema once the steroid has been stopped.
However, as noted above, if too potent a topical steroid is used on a thin area of skin such as the face, local irritation and burning can occur. Skin thinning and discoloration can also occur so it is very important for you to know exactly what part of the body your topical steroid should be used on.
A common question I get asked involves how long it is safe to use the topical steroid. A physician may have given you instructions to not use it longer than a certain time period such as 2 weeks consecutively. In my clinical experience, using a topical steroid consecutively for 2 weeks should almost never occur. In the vast majority of cases the inflammation should be controlled within the first 3-4 days and topical steroid use should not be needed past 5-7 days tops. Once the inflammation has been controlled, topical steroid use should stop. From there, non-medicated creams should take their place and be applied diligently.
If the topical steroid does not dramatically improve your flare with the first 3-4 days, you should contact your doctor and consider the following scenarios:
As discussed, previously, low potency topical steroids do not do well in thicker areas of the skin (i.e the hands) and are likely not strong enough to calm the flare
At times, the topical steroid just needs to be changed. For a variety of reasons, you may not respond to a certain topical steroid as well as another one, even if the potency is appropriate. In my experience this scenario is not as common as some of the others but does occur.
Steroids will not work well or not at all if there is a co-infection with a bacteria such as Staph. This needs to be addressed for the topical steroid to be successful.
Contact sensitivities can occur to the steroid molecule or to other ingredients in the topical preparation. This is not common but should definitely be considered if the steroid causes irritation or worsening of the site. In this case, switching the steroid class is needed. Patch testing on an unaffected area of skin can be considered to confirm the diagnosis.
This is something that must be considered especially if steroids do not have any effect. Biopsies and/or trials of other therapies such as antibiotics or antifungals may be necessary.
