Topical corticosteroids are steroid drugs you apply to the skin. They offer a variety of benefits if you have an inflammatory skin disease like psoriasis. Unlike oral steroids, in which the active drug is disseminated through the bloodstream, topical steroids penetrate the skin and go directly to the affected cells.
Topical corticosteroids can aid in the treatment of psoriasis by:
- Reducing inflammation
- Slowing the hyperproduction of skin cells
- Reducing the appearance of psoriatic skin lesions
- Alleviating itching and discomfort
- Aiding the shedding of scaly skin
How Corticosteroids Work
Psoriasis is an inflammatory autoimmune disease in which the immune system suddenly regards normal skin cells as harmful. In response to the perceived threat, the immune symptom will launch an inflammatory attack on the middle and upper layers of skin (known, respectively, as the dermis and epidermis).
The inflammation, in turn, will accelerate the production of skin cells, causing them to build up and form dry, scaly lesions known as plaques.
Corticosteroids mimic the effects of a hormone your body produces naturally in the adrenal glands. The hormone, called cortisol, is released by the body to control inflammation.
By taking corticosteroid drugs, either topically or by mouth, abnormal autoimmune inflammation can be reduced and, with it, the symptoms of psoriasis.
Not all topical corticosteroids are the same. Your healthcare provider will prescribe the option best suited for you based on, among other things, the location of your plaques and the general state of your skin. There are several different formulations they can choose from:
- Ointments are made from petrolatum (petroleum jelly) and tend to be greasy.
- Creams are medium-weight and well-suited for delicate skin.
- Lotions are lightweight due to being water-based. They’re a bit weaker than creams and ointments.
- Oils can be used for whole-body treatment or as an overnight scalp treatment.
- Gels are non-greasy and easily absorbed into the skin, making them great for the scalp and other hairy areas.
- Foams can also be easily massaged into the scalp.
- Tapes are infused with corticosteroid drugs. They are appropriate for thicker plaques on the elbows or knees.
Your healthcare provider will choose the option that delivers the appropriate amount of drug based not only on the drug concentration but the absorptive capacity of the skin.
Ointments, for example, are typically stronger than creams and may be better for thicker plaques. Lotions or creams, by contrast, may be appropriate for the delicate skin of the face, armpits, or groin.
Foams are especially effective in that they penetrate into the deeper layers of skin. Because of this, a less-potent corticosteroid may be sufficient when used in this form.
There are seven different categories of topical corticosteroids based on strength. The mildest, categorized as Class VII, include over-the-counter 1% hydrocortisone cream. The strongest, known as Class I, include more aggressive preparations like clobetasol.
Keep in mind that the greater the potency of a topical corticosteroid, the greater the risk of side effects. It’s important that your psoriasis be treated based on its severity.
Topical Steroid Class I
These topical steroids have the highest potency overall:
- Diprolene (betamethasone dipropionate 0.05% ointment or gel)
- Temovate (clobetasol propionate 0.05% cream, ointment, or shampoo)
- Ultravate (halobetasol propionate 0.05% cream, ointment, or lotion)
- Vanos (fluocinonide 0.1% cream)
Topical Steroid Class II
These topical steroids are considered highly potent:
- Cyclocort (amcinonide 0.1% ointment)
- Halog (halcinonide 0.1% cream, ointment, or solution)
- Lidex (fluocinonide 0.05% cream, gel, ointment, or solution)
- Topicort (desoximetasone 0.25% cream or ointment)
Topical Steroid Class III
These topical steroids are considered potent:
- Cutivate (fluticasone propionate 0.005% ointment)
- Elocon (mometasone furoate 0.1% ointment)
- Florone (diflorasone diacetate 0.05% cream)
- Topicort LP (desoximetasone 0.05% cream)
Topical Steroid Class IV
These topical steroids are considered medium potent:
- Cordran (flurandrenolide 0.05% cream, ointment, or lotion)
- Cutivate (fluticasone propionate 0.05% cream)
- Kenalog (triamcinolone acetonide 0.025% cream or 0.1% lotion)
- Synalar (fluocinolone acetonide 0.025% cream or ointment)
- Triderm (triamcinolone acetonide 0.1% cream, ointment, or lotion)
Topical Steroid Class V
These topical steroids are considered lower-mid potent:
- Westcort (hydrocortisone valerate 0.2% cream or ointment)
- Locoid (hydrocortisone butyrate 0.1% ointment)
- Dermatop (prednicarbate 0.1% cream or ointment)
- Pandel (hydrocortisone probutate 0.1% cream)
Topical Steroid Class VI
These topical steroids are considered mild:
- DesOwen (desonide 0.05% lotion, gel, cream, or ointment)
- Kenalog (triamcinolone acetonide 0.025% cream or lotion)
- Synalar (fluocinolone acetonide 0.01% cream, solution, or shampoo)
Topical Steroid Class VII
These topical steroids are the least potent overall:
- Hytone (hydrocortisone 2.5% cream or lotion)
- Hydrocortisone 1% cream, ointment, or lotion
- Hydrocortisone 2% and 2.5% cream, ointment, or lotion
- Hydrocortisone acetate 2% and 2.5% cream or ointment
How to Apply Safely
Topical corticosteroid should be applied in a thin layer and massaged into the affected area one to four times per day as directed. The treatment typically lasts until the psoriatic plaques resolve. In some cases, a stronger topical drug will be used to penetrate thickened plaques and switched to a milder form once the major scaling has been reduced.
Some corticosteroids are used on an intermittent basis whenever signs of a flare develop. These will usually be milder Class VI or VII drugs that can be applied when needed. Always check the expiration date and let your healthcare provider know well in advance if you need a refill.
Never apply a topical corticosteroid to skin other than that directed by your dermatologist. This is especially true with respect to the genitals and face.
Unless your healthcare provider tells you otherwise, never apply topical corticosteroids to the eyelids or under the eyes. Topical steroids should never be used internally or applied to cracked, bleeding, or infected skin.
Class I steroids are not just a little stronger than Class VII; they are between 600 and 1,000 times stronger. These ultra-high-potency preparations have the greatest efficacy overall, but also the most side effects. As a result, a Class VII topical steroid may only be prescribed for two to three weeks, while a Class I drug may be used for longer periods.
The incidence of side effects increases in tandem with the strength of the drug and the duration of treatment. As such, it is important to use the corticosteroid as prescribed and to not assume that “more is better.” In most cases, the opposite is true.
Among the possible sides effects are:
- Stinging or burning sensations
- Skin redness (erythema)
- Skin thinning (atrophy)
- Stretch marks (striae) in the armpits or groin
- Easy bruising and tearing of the skin
- Enlarged blood vessels (telangiectasia)
- Increased localized hairiness (hypertrichosis)
Many of the more severe symptoms can occur after weeks or months of treatment. It is important to stop treatment and call your healthcare provider should any skin abnormality develop. Any damage to the skin may be permanent.
If a topical corticosteroid is used for an extended period, it may induce withdrawal symptoms if stopped abruptly. Withdrawal symptoms may include a severe rebound of psoriasis symptoms, extreme sensitivity to heat or cold, and resistance to topical medications.
To prevent steroid withdrawal, your healthcare provider will taper the dose gradually over weeks or months. If you experience a worsening of symptoms during the tapering phase, call your practitioner.
Castela E, Archier E, Devaux S. Topical corticosteroids in plaque psoriasis: a systematic review of efficacy and treatment modalities. Journal of the European Academy of Dermatology and Venereology. 2012;26:36-46. doi:10.1111/j.1468-3083.2012.04522.x
Gabros S, Zito PM. Topical Corticosteroids. [Updated 2019 Dec 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.
Jacob SE, Steele T. Corticosteroid classes: A quick reference guide including patch test substances and cross-reactivity. Journal of the American Academy of Dermatology. 2006;54(4):723-727. doi:10.1016/j.jaad.2005.12.028
Das A, Panda S. Use of Topical Corticosteroids in Dermatology: An Evidence-based Approach. Indian J Dermatol. 2017;62(3):237–250. doi:10.4103/ijd.IJD_169_17
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