Topical steroids

What are topical steroids?

The word topical here means any medicine that can be put on your skin, into your eye or ears, or up your nose, breathed in through an inhaler, or put up your bottom by use of a suppository or applicator.

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 Asthma Inhalers and Inhalers for COPD (including Inhaled Steroids).

How do topical steroids work?

• 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.

Types of topical steroids

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.

Some of these steroids can be used in several ways. 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:

• Skin.

• Nose.

• Eyes.

• Ear.

• Gut.

• 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.

The strength of topical steroid prescribed depends upon the condition being treated and how severe the condition is. For example, in severe psoriasis, a doctor may prescribe a strong steroid such as betamethasone. But, where there is mild eczema on the 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 the 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 fusidic acid.)

If the 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 can you use topical steroids?

How often topical steroids are applied will depend upon the condition and how severe it is. For most conditions, topical steroids are normally 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 applied up to 4-6 times a day in inflammation of the eyes.

For more information see the leaflet that comes with the medicine.

How long can you use topical steroids

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 to ten days. 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). This will be explained when the topical steroid is prescribed.

Stopping topical corticosteroids

If a strong topical steroid has been used for a long period of time, the amount of topical steroid used might need to be reduced over a period of weeks and then stopped instead of stopping suddenly. This is because when it is stopped suddenly the 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?

Some topical corticosteroids can be bought 'over the counter' without a prescription. For example, for dermatitis, the steroid cream called hydrocortisone 1% can be bought from a pharmacy. This should not be applied to the face unless advised to do so.

This is because long-term use can damage the skin and this would be more noticeable on the face than the rest of the body. Usually only weak steroids are used on the face and for a very short time only. Those which are suitable are prescription-only.

Caution needs to be used when buying steroid creams over the counter. They can make some conditions worse, not better. For example, athlete's foot will get worse with steroids, as will eczema herpeticum and perioral dermatitis.

Some steroid nose (nasal) sprays can be bought over the counter to treat hay fever - for example, beclometasone nasal spray and fluticasone nasal spray - in most areas of the UK these are expected to be bought rather than prescribed. A pharmacist can discuss how to use them safely.

Side-effects of topical steroids

Most people who use topical steroids have very few or no side-effects.The likelihood of developing side-effects depends on the length of time the medicine is used for, how much is used and how strong the steroid is.

It is not possible to list all the side-effects here. However, those listed below are the more important and common side-effects. For a full list of side-effects see the leaflet that comes with the 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.

  • Acne.

  • Rosacea.

  • Hair growth at the site of application.

• The more serious of these would normally only occur when using strong or very strong steroid creams or ointments for a long time.

• Nose (nasal) sprays and drops - dryness and irritation of the nose, as well as nosebleeds, have been reported. The nasal spray may need to be stopped 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.

As a general rule, the lowest dose of topical steroid should be used for the shortest length of time that works to control symptoms. Longer term use of topical steroids should be monitored.