Topical steroids are medicines that are used to treat a large number of conditions that cause inflammation - for example, eczema, psoriasis, hay fever, allergies and certain conditions of the eyes. They work by reducing inflammation and irritation. Topical steroids can be applied to the skin, eyes and nose as well as being inhaled into the lungs or inserted into the rectum. When they are used in the right way they have very few side-effects, and they have far fewer side-effects than steroid tablets (oral steroids).
What are topical steroids?
Steroids are hormones that occur naturally in the body. Steroid medicines are man-made and are similar to the natural hormones made in the body. The type of steroids used to treat disease are called corticosteroids. They are different to the anabolic steroids which some athletes and bodybuilders use. Anabolic steroids have very different effects.
Topical steroids are available as creams, ointments, lotions, suppositories, drops (for the eyes, nose and ears), and nose (nasal) sprays. Steroid inhalers for the lungs are also a type of topical steroid. These are covered in the separate leaflets called Inhalers for Asthma (including Inhaled Steroids) and Inhalers for COPD (including Inhaled Steroids).
Topical steroids work by:
- Reducing redness and swelling (inflammation) in the part of the body they are applied to
- Suppressing the body's immune system.
- Stopping cells from multiplying.
- Reversing enlargement of blood vessels in the area they are applied to. They cause a narrowing of the blood vessels.
This leaflet gives an overview of topical steroids, including their main possible side-effects. There is more information in the separate leaflets called Topical Steroids for Eczema, Fingertip Units for Topical Steroids and Steroid Nasal Sprays.
What types of topical steroids are there?
There are many topical steroids available. These are some of the more commonly used ones in the UK:
- Creams and ointments, such as hydrocortisone, clobetasone, betamethasone, clobetasol and mometasone. There are many others. These are used for skin conditions such as eczema, contact dermatitis and psoriasis.
- Nose (nasal) sprays such as beclometasone, fluticasone, mometasone and budesonide. These are used for conditions such as hay fever, allergies and non-cancerous swellings that grow inside the nose or sinuses (nasal polyps).
- Nose drops such as betamethasone. These are used for conditions such as hay fever, allergies and nasal polyps.
- Eye drops or ointments such as betamethasone, dexamethasone, prednisolone, loteprednol, fluorometholone and rimexolone. These are used to reduce inflammation after operations to the eye. They are also used for certain other conditions which cause the eye to be inflamed.
- Ear drops such as betamethasone, prednisolone and dexamethasone. These are used when the ear canal is inflamed - for example, with eczema or an infection (otitis externa).
- Preparations which can be inserted into the rectum, which may be suppositories, ointments or foams. These include prednisolone, hydrocortisone and budesonide. These are for conditions which involve inflammation of the gut - for example, ulcerative colitis or Crohn's disease.
You will see that some of these steroids are used in several ways. For example, hydrocortisone comes in a cream, ear drops and a foam for the rectum. There are many types and brands of topical steroid. They are generally grouped into four categories depending on their strength - mild, moderately potent, potent and very potent. There are various brands and types in each category. For example, hydrocortisone cream 1% is a commonly used steroid cream and is classed as a mild topical steroid. Betamethasone is a stronger (more potent) commonly used steroid cream. The greater the strength (potency), the more effect it has on reducing inflammation but the greater the risk of side-effects with continued use.
When are topical steroids prescribed?
Topical steroids are prescribed to treat a large number of conditions. Some of these conditions are listed in the section above. You will see topical steroids can be used to treat problems with the:
- Lungs (if inhalers are included as topical steroids)
Which topical steroid is usually prescribed?
Creams are usually best to treat moist or weeping areas of skin. Ointments are usually best to treat areas of skin which are dry or thickened. Lotions may be useful to treat hairy areas such as the scalp.
Which strength of topical steroid is prescribed depends upon the condition being treated and how severe the condition is. For example, if you have severe psoriasis, your doctor may prescribe a strong steroid such as betamethasone. But, if you have a mild skin condition on your face, a weak topical steroid is usually prescribed - for example, hydrocortisone 0.5%.
Topical steroid creams are sometimes prescribed as a combined cream together with another ingredient. For example if your inflamed skin has an infection with germs which are bacteria, the steroid cream may also contain an antibacterial medicine. (It is usually combined with an antibacterial medicine called fucidic acid.) If your inflamed skin has an infection with a yeast (fungus), the steroid cream may also contain an antifungal medicine. (Common antifungal medicines used are clotrimazole and miconazole.)
How often are topical steroids usually applied?
How often topical steroids are applied will depend upon the condition you have and how severe it is. For most conditions, topical steroids are normally applied or used once or twice a day. For example, people who have eczema or psoriasis usually apply their steroid creams or ointments once or twice a day.
Some topical steroids can be applied more often. For example, dexamethasone eye drops are usually applied 4-6 times a day if you have inflammation of the eye.
For more information see the leaflet that comes with your medicine.
What is the usual length of treatment?
Most doctors prefer to prescribe topical steroids for as short a period of time as possible, in particular those applied to the skin. Strong topical steroids are normally not used for much longer than one week. This is because topical steroids can have a number of side-effects. However, the length of treatment normally depends on the condition being treated and how severe the condition is. Some people need to use topical steroids in the long term (for example, steroid nose (nasal) sprays for allergies). Other people may only need to use them for a week or so (for example, for mild dermatitis). Some people need to use them for months (for example, a cream for psoriasis or a spray for hay fever). Your doctor will explain when they prescribe the topical steroid.
Stopping topical corticosteroids
If you use a strong topical steroid for a long period of time you will usually need to reduce the amount you use over a period of weeks and then stop. For example, if you have been using a potent steroid cream to treat psoriasis. This is because when it is stopped suddenly your condition may come back quickly. If topical steroids have only been used for a short time they can usually be stopped abruptly.
Can you buy topical corticosteroids?
You can buy some topical corticosteroids "over-the-counter" without a prescription. For example, for dermatitis, you can buy the steroid cream called hydrocortisone 1% from your pharmacy. Do not apply this to your face unless your doctor has told you to do so. This is because it may trigger a skin condition affecting the face (acne or rosacea.) Long-term use may also damage the skin. On your face this would be more noticeable than the rest of your body. So usually only weak steroids are used on the face. Those which are suitable are prescription-only.
You can also buy some steroid nose (nasal) sprays to treat hay fever - for example, beclometasone nasal spray and fluticasone nasal spray.
Your pharmacist will discuss how to use them safely.
What are the side-effects of topical steroids?
Most people who use topical steroids have no side effects, or very few. How likely you are to have side-effects depends on how long you use the medicine for, how much is used or applied and how strong the steroid is.
It is not possible to list all the side-effects here. However, listed below are some of the more common and important ones. For a full list of side-effects see the leaflet that comes with your medicine.
- Creams and ointments - burning and stinging may occur in the first two days but usually get better after this. Other side-effects that have been reported include:
- Thinning of the skin.
- Permanent stretchmarks.
- Allergic contact dermatitis.
- Hair growth at the site of application.
- The more serious of these would normally only affect you if you use a strong or very strong steroid cream or ointment for a long time.
- Nose (nasal) sprays and drops - dryness and irritation of the nose, as well as nosebleeds have been reported. You may have to stop your nasal spray for a while if any of these occur. Other side-effects include reddening of the skin, rash, itching, and headache. Some people have reported that their sense of smell and taste is disturbed after using a nasal steroid.
- Eye drops - increased pressure inside the eye, cataracts, and blurred vision have been reported. Blurred vision clears very quickly after using an eye drop. People using steroid eye drops are also more likely to have eye infections and inflammation.
Even with topical steroids, some of the medicine gets through the skin and into the bloodstream. The amount is usually small and causes no problems unless strong topical steroids are used regularly on large areas of the skin. The main concern is with children who need frequent courses of strong topical steroids. The steroid can have an effect on growth. Therefore, children who need repeated courses of strong topical steroids should have their growth monitored.
How to use the Yellow Card Scheme
If you think you have had a side-effect to one of your medicines you can report this on the Yellow Card Scheme. You can do this online at the following web address: www.mhra.gov.uk/yellowcard.
The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that medicines may have caused. If you wish to report a side-effect, you will need to provide basic information about:
- The side-effect.
- The name of the medicine which you think caused it.
- The person who had the side-effect.
- Your contact details as the reporter of the side-effect.
It is helpful if you have your medication - and/or the leaflet that came with it - with you while you fill out the report.
Dr Mary Harding
Dr Colin Tidy