Medications

Topical Steroids | The ‘Emergency Brake’ for Dermatitis

Topical steroids are medications that most quickly and powerfully calm dermatitis, much like an ’emergency brake’.

However, just as brake pads wear out with frequent use, excessive steroid use can weaken the skin barrier.

Therefore, it is important to use them wisely only when absolutely necessary.

Infographic comparing steroids to an emergency brake — it stops powerfully in an emergency, but continuous use can wear out the brake pads (skin barrier).

Table of Contents

1. What are Topical Steroids?

Topical steroids are medications made for direct application of synthetic corticosteroids to the skin. Their main mechanisms of action are as follows:

  • They suppress the activity of immune cells and reduce the release of inflammatory mediators (cytokines).
  • They constrict blood vessels, alleviating erythema and edema.

They are classified into 7 grades based on their potency (measured by their vasoconstrictive effect) and come in various formulations such as ointments, creams, and lotions.

2. Reasons for Cautious Use

While steroids are powerful anti-inflammatory drugs, long-term use can weaken the skin barrier.1

The ultimate goal of treating chronic dermatitis is to restore the barrier, but steroid use can conflict with this goal.

3. Very Useful When Skin is Thickened

When atopic dermatitis recurs over a long period, the skin can become hard and thickened (lichenification). In such cases, the ‘skin-thinning side effect’ of steroids is very useful.

After reducing skin thickness with potent steroids, using drugs like calcineurin inhibitors can yield better results than using them alone immediately.

4. Grades and Formulations

Topical steroids are classified into grades from 1 (most potent) to 7 (least potent) based on their strength, and each formulation (ointment, cream, lotion, solution, gel) has different suitable uses.

You can find information on grades, formulations, and product lists by grade in the article Steroid Ointment Grades.

A close-up photo comparing the texture and viscosity differences between steroid cream (opaque white) and steroid ointment (translucent jelly-like) squeezed side-by-side on glass — for reference when choosing a formulation.

5. Absorption Rate

Even the same topical medication can be absorbed in vastly different amounts depending on the body area, due to varying skin thickness.2

A chart showing the difference in steroid absorption rates across various body areas. It highlights that the eyelids and genital area have the highest absorption rates.

Compared to the forearm, the genital area shows approximately 42 times higher absorption, the chin area approximately 13 times, and the forehead approximately 6 times. Conversely, the soles of the feet have a very low absorption rate of 0.14 times.2 This is why using high-potency steroids on the face can be risky.

The condition of the skin barrier at the application site also significantly affects the absorption rate. If the barrier is damaged, the medication may be absorbed more than expected.

Infographic showing that steroid absorption rate can sharply increase with the degree of skin barrier damage.

6. How to Use

These are the basic principles for safe use of topical steroids.

  1. Frequency of Application — 1 to 2 times a day is usually sufficient. Increasing the frequency does not proportionally increase effectiveness and only raises the risk of side effects.3
  2. Tapering — Abrupt discontinuation can lead to rebound. It is safer to gradually reduce the frequency of application to 2-3 times a week before stopping, or to switch to calcineurin inhibitors. Information on calcineurin inhibitors can be found on the Elidel and Protopic pages.
  3. Concurrent Use of Moisturizers — Steroid ointments can achieve the same effect with a smaller dose when used with moisturizers. One study even showed that a group using steroids once a day with a moisturizer had equivalent effects to a group using steroids twice a day alone.4 For guidance on choosing a moisturizer when you have dermatitis, please refer to the MD Cream Guide.

7. Precautions by Condition

Atopic Dermatitis

It is useful for rapidly reducing inflammation during acute exacerbations. However, as it can further weaken the barrier, the principle is to use it for a short period at sufficient potency when necessary, then switch to calcineurin inhibitors.

Rosacea

It is not recommended for use. The German Dermatological Society guideline (2022) states that “steroids are not indicated for rosacea and can even worsen it.”5 The National Rosacea Society (NRS) in the US also excludes steroids from treatment options.6

Seborrheic Dermatitis

Use with caution. If local immunity is suppressed by steroids, an environment is created where Malassezia can proliferate more easily, leading to a pattern of temporary improvement followed by worsening upon discontinuation.

8. Conclusion

While topical steroids have powerful anti-inflammatory effects, due to their impact on the barrier, it is crucial to use them strategically only when the purpose is clear.

When using them, the grade and duration of use must always be determined by considering both the body area and the condition of the skin barrier.

References

  1. Hengge UR, Ruzicka T, Schwartz RA, et al. Adverse effects of topical glucocorticosteroids. J Am Acad Dermatol. 2006;54(1):1-15.
  2. Feldmann RJ, Maibach HI. Regional variation in percutaneous penetration of 14C cortisol in man. J Invest Dermatol. 1967;48(2):181-3.
  3. Saeki H, Ohya Y, Furuta J, et al. English version of clinical practice guidelines for atopic dermatitis 2021. J Dermatol. 2022;49(10):e315-e375.
  4. Lucky AW, Leach AD, Laskarzewski P, Wenck H. Use of an emollient as a steroid-sparing agent in the treatment of mild to moderate atopic dermatitis in children. Pediatr Dermatol. 1997;14(4):321-4.
  5. Clanner-Engelshofen BM, Bernhard D, Dargatz S, et al. S2k guideline: Rosacea. J Dtsch Dermatol Ges. 2022;20(8):1147-1165.
  6. Thiboutot D, Anderson R, Cook-Bolden F, et al. Standard management options for rosacea: The 2019 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2020;82(6):1501-1510.

Frequently Asked Questions

Is Grade 1 good and Grade 7 bad?

No. Grades indicate differences in potency. Higher grades are suitable for thick areas like the palms, while lower grades are appropriate for thin areas like the face. It is important to choose the grade that matches the body area and skin condition.

How long should I use it?

During the acute phase, continuous use for 1 to 2 weeks is usually recommended. If longer use is needed, adjustments such as reducing the frequency of application or lowering the grade are necessary.

Can it be used on the face?

Yes, if necessary. However, since the face has a high absorption rate, it is best to use weaker steroids (Grade 6-7) for a short period.

Can I use it during pregnancy?

Topical steroids have minimal systemic absorption and are relatively safe to use during pregnancy. However, strong grades should be avoided over large areas for prolonged periods, and use must always be discussed with your doctor.

What should I do if the condition immediately flares up again after stopping the medication?

This may be a rebound phenomenon occurring due to abrupt discontinuation or if the inflammation has not been sufficiently controlled. You can gradually reduce the frequency of application (tapering) or switch to calcineurin inhibitors (Elidel · Protopic).