Topical corticosteroids are the mainstay for many skin conditions and disorders given their anti-inflammatory, antiproliferative, and immunosuppressive properties. They are available in a variety of strengths and dosage forms, including creams, ointments, lotions, gels, foams, and solutions. In this article, we provide education and clinical considerations for when to use high potency versus low potency topical steroids.
Potency of Topical Corticosteroids
Topical steroids are categorized into seven different groups based on their potency, with 1 being the highest potency and 7 being the lowest potency. Factors that influence the potency of a topical steroid include:
- Corticosteroid – The potency of a steroid is determined based on its vasoconstrictive property and correlates with its clinical efficacy. Clobetasol is a good example of a very potent topical corticosteroid and hydrocortisone is an example of a commonly used low potency topical steroid.
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- Vehicle – Vehicles are used to deliver steroids to the site of action (i.e. the stratum corneum). Selecting the correct vehicle is critical when treating dermatologic conditions as each one offers its own benefits and limitations. Ointments and creams are the most commonly used vehicles. Ointments are oil-based formulations that provide lubrication and occlusion, promoting skin hydration. This makes them ideal for thicker-skinned areas. Creams, on the other hand, are water and oil emulsions that incorporate easily into the skin. Creams are more suitable for areas in which ointments cannot be used but tend to be less potent in comparison.
- Occlusion – Occlusion increases hydration of the skin, increasing the absorption of the corticosteroid, and ultimately, increasing its potency. Occlusion may increase the potency of an agent by 100-fold in some cases. Here again, ointments are going to provide greater occlusion and increase potency compared to steroid creams.
- Hydration – Hydration promotes skin permeation, thereby increasing the effectiveness of the steroid.
- Integrity – Damaged or inflamed skin is more permeable and increases the absorption of steroids.
- Thickness – Thicker-skinned areas pose a larger barrier to steroids and therefore, are more resistant to steroid permeation.
Selecting a Topical Corticosteroid – When to Use High Potency Versus Low Potency Steroids
When treating a skin disorder, it is necessary to consider the indication for use, the severity of the condition, and the area of treatment. Topical corticosteroids are most effective for relieving symptoms associated with inflammation, hyperproliferation, and immunologic mediation.
Low-potency agents are generally considered the safest for chronic use, use in children, larger areas of skin, and thinner or sensitive areas (e.g. face, groin). They are most appropriate for milder conditions, such as perianal inflammation, hemorrhoids, and diaper dermatitis. Topical corticosteroids are used to relieve symptoms associated with these conditions (e.g. pain, inflammation, itchiness). Since these conditions affect a relatively small area of skin that is thinner and more hydrated, lower potency agents are more suitable as they are able to easily permeate these areas. Using a higher potency agent would significantly increase the risk for systemic absorption and adverse effects.
Higher potency agents are reserved for more severe conditions and areas of dry, thick, or tough skin. Super high-potency topical steroids have the most potent anti-inflammatory effect, making them the most effective for treating severe or resistant conditions. These agents are generally not used first-line but are reserved for more severe or resistant conditions, such as psoriasis and significant allergic contact dermatitis (e.g. poison ivy). Topical steroids provide symptomatic relief by inhibiting cell proliferation (preventing scales and plaques), reducing swelling, and suppressing inflammation and thereby alleviating itching and redness. Higher potency agents also facilitate steroid delivery to its site of action. Poison ivy can be transferred between objects and other parts of the body. Higher potency agents are able to penetrate skin that is tougher or thicker, such as hands. Lower potency agents would exhibit lesser anti-inflammatory effects and may fail to relieve symptoms given their reduced penetration.
Below, we provide a table of clinical considerations for when to use high potency versus low potency topical steroids.
|High-Potency (Groups I-III)||-Most potent vasoconstrictive, anti-inflammatory, and anti-proliferative effects|
-Ideal for severe dermatoses on non-facial, non-intertriginous areas Ideal for areas of thick, dry skin (e.g. palms of hands, soles of feet)
-Best for treatment of smaller areas
|-Limited duration of use (max of 3 weeks)May require a “steroid-free” period|
-Taper required for longer durations of use (rebound potential)Cannot be used on face, groin, armpit, or skin folds
-Not recommended for use on large areas (risk of systemic absorption and adverse effects)
-Potential for systemic side effects
-Cannot be occluded
–Atopic dermatitis (resistant)
-Contact dermatitis (severe)
-Eczema (hand, severe)
-Lichen planus, sclerosus (skin), or simplex chronicus
|Medium-Potency (Groups IV-V)||-Ideal for mild-moderate non-facial, non-intertriginous areas|
-Effective option for some severe conditions
-Duration of use up to 6-8 weeks
|-May not be effective for resistant conditions||-Anal inflammation (severe)|
-Lichen sclerosus (vulva)
-Scabies (after scabicide)
|Low-Potency (Groups VI-VIII)||-Safest (lowest risk for systemic absorption)|
-Appropriate for long-term use (up to 3 months) depending on the area of use
-Appropriate for treating larger areas
-Best for thinner, more sensitive areas (e.g. face, intertriginous areas, armpits, groin)
-Use in children
|-Not effective for treating moderate-severe conditions|
-Unable to permeate thicker areas of skin (e.g. palms of hands, soles of feet)
|–Diaper, eyelid, or facial dermatitis|
When to use high potency versus low potency topical steroids ultimately comes down to the condition, the severity of the condition, and the area affected. Ideally, the lowest potency agent should be used for the shortest amount of time possible. Therefore, lower potency agents should be considered first whenever possible to mitigate side effects while managing symptoms. However, there are scenarios where super-potent or higher-potency agents are necessary for alleviating symptoms. Topical corticosteroids should be used cautiously and discontinued once the condition is resolved. Inappropriate use can lead to undesirable side effects (e.g. atrophy, systemic effects), effectiveness, or worsening of symptoms.
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This article was written by Alyssa Butterfield, PharmD Candidate, in collaboration with Eric Christianson, PharmD, BCPS, BCGP