Family doctor

Products

There are a number of different steroid creams and ointments, some are stronger than others - the strength is decided by the medicine, the amount of the medicine in the product and sometimes the base of the medicine. Sometimes the cream or ointment may be produced in a diluted form, e.g. Betnovate RD is only a quarter of the strength of Betnovate, or Synalar in some countries may be in different dilutions. These are not available in all countries, and in general are less recommended.

Very Strong

• Clobetasol proprionate 0.05% (Dermovate; Dermol). Apply once or twice daily.
• Betamethasone dipropionate 0.05% in a propylene glycol base (Diprolene). Apply once or twice daily.

Strong

• Beclomethasone valerate 0.1% (Betnovate). Apply two to three times daily until skin improves then once daily or less.
• Betamethasone dipropionate 0.05% (Diprosone). Apply twice daily initially then once daily.
• Mometasone furoate (Elocon). Apply once daily.
• Fluocinolone acetonide 0.025% (Synalar). Apply up to three times daily.
• Diflucortolone valerate 0.1% (Nerisone). Apply two or three times daily initially then once daily.
• Methylprednisolone aceponate 0.1% (Advantan). Apply once daily.
• Hydrocortisone 17-butyrate 0.1% (Locoid). Apply one to four times daily.
• Fluticasone propionate 0.05/0.005% (Cutivate). Apply once or twice daily.

Moderate

• Triamcinolone acetonide 0.02%/0.05% (Aristocort). Apply three to four times daily.
• Clobetasone 17-butyrate 0.05% (Eumovate). Apply up to four times daily.

Mild

• Hydrocortisone 1% (BK with HC, Cortaid, Egocort, HC45, Lanacort, Skincalm). Apply three to four times daily.

Use:

Steroid creams are used to reduce inflammation and itchiness for example in eczema or dermatitis. The stronger the product the more likely it is to cause side effects, so generally the mildest steroid that will work is used. It is not recommended to use anything stronger than hydrocortisone 1% on babies or the face. If possible children should be treated with hydrocortisone 1% rather than stronger products. It is common in adults to use a strong product to get a problem area (other than the face) under control then use a moderate or mild product to maintain that control.

An ointment base is greasier than a cream, and is recommended for drier areas, while a cream may be more suitable if the problem area is weeping (oozing). A lotion is recommended for especially hairy areas.

If an area of skin is covered e.g. with a plastic film, the steroid can be more effective, but it also can increase side effects so only do this if the doctor recommends it.

You can get used to one product and so sometimes if you are not responding to a product, switching to another will give relief again.

Sometimes steroids are combined with another ingredient or two, usually either an antibacterial or an antifungal. These combination products are useful if infection and inflammation are both present. Examples include Daktacort, Pimafucort, Betnovate C and Canesten HC.

Cautions:

Other than the mild products for a short time, the steroid creams and ointments should be used under the doctor's advice.

Do not use in:

• Acne rosacea (a red bumpy condition on the cheeks and chin usually in adults)
• Pimples
• Dermatitis around the mouth
• Skin problems caused by infection (e.g. cold sores, chickenpox, tinea, school sores)
• Ulcers or other wounds
• Allergy to the ingredients

Take special care:

• In infants under 1 year (hydrocortisone 1% only and remember the nappy can increase the penetration of the drug)
• In children (use the mildest product possible)
• When treating the face (use only mild products and for the shortest time possible)
• When using around the eyes as glaucoma and cataracts can be caused by steroids getting into the eye
• In psoriasis - this is best treated under a specialist
• In covered areas as the warm moist conditions may encourage bacteria to grow - clean the skin well before applying
• When using in the flexures (e.g. behind the knee, inside the elbow) or skin folds (e.g. under the breasts, around the groin area, between the toes) - penetration can be increased in these areas
• Large amounts should not be used in pregnancy

Side effects:

Side effects are more likely with the stronger steroids, with large amounts applied, with use for a long time and if the area being treated allows more drug penetration (e.g. the face, covered areas or skin folds). Therefore, it is recommended to use the mildest product that works for you, to use moisturisers (emollients) and soap substitutes to help the skin, and to use for the shortest time you can. Usually the steroid cream or ointment should be applied fairly thinly on the problem area, although sometimes your doctor may tell you to put more on. If a mild to moderate product is used for a relatively short time, side effects are uncommon.

• Skin thinning after a few weeks of use can occur but the skin goes back to normal if the product is stopped for a while
• Burning, stinging and irritation can sometimes occur
• Striae (stretch marks) can occur with stronger products
• Reduced skin colour
• Acne and infections in hair follicles
• Small areas of permanently dilated blood vessels giving a red area of skin
• Dermatitis around the mouth or rosacea on stopping the steroid - this is why only mild products should be used on the face
• Glaucoma and cataracts if steroids get into the eye
• Small haemorrhage in the skin
• Contact dermatitis to ingredients in the steroid cream
• With large quantities or if using potent products in children adrenal suppression can occur

There may be other side effects, so if you have any unexpected symptoms while taking this medicine, tell your doctor or pharmacist.

Interactions:

No interactions are expected.

Patient information:

• Follow the instructions on the label of the medicine or as directed by your doctor.
• Do not use more often than the doctor recommends.
• Do not use someone else's steroid cream or give your cream to others.
• Take especial care with using steroids on the face - if possible avoid around the eyes, do not use anything stronger than hydrocortisone and use for a short time and only under a doctor or pharmacist's supervision.
• Use soap substitutes such as Aqueous Cream, Emulsifying Ointment, Pinetarsol, Sebamed, BK Wash or QV Wash. These are much better for skin with dermatitis than soap. Apply these to wet skin and wash off.
• Use as much moisturiser as you can - the greasier the moisturiser the better it works (generally). Regular use of moisturiser will reduce the amount of steroid cream you need to use. Good moisturisers include Aqueous Cream, Emulsifying Ointment, BK, Alpha-Keri, QV Lotion or Sebamed.
• Use a thin application of the steroid cream or ointment unless your doctor suggests to use more.
• Take care that you don't underuse steroid creams and ointments - short-term use (e.g. a few weeks) is unlikely to be associated with side effects.
• If your skin is not getting better with a steroid check with your doctor as you may have become hypersensitive to that product, you may have become used to the product, you may need a stronger product or you may have an infection.
• Once the skin is under control it is usual to apply the cream less often, stop using it or move onto a milder product - your doctor will be able to advise you on this.