It is important to prescribe the appropriate potency of steroid according to the severity of the disease. Flare-ups can be treated with a potent or very potent steroid and then stepped down to an appropriate potency of steroid or even an emollient. By treating actively, you are more likely to get the skin condition under control.

The long-term use of potent and very potent steroids should only be recommended by a dermatologist, GPwSI or nurse specialist.

NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). One of these conditions is mild irritant dermatitis.

Many of these products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

MHRA Drug Safety Update (September 2021): topical corticosteroids: information on the risk of topical steroid withdrawal reactions

• long-term continuous or inappropriate use of topical corticosteroids, particularly those of moderate to high potency, can result in the development of rebound flares after stopping treatment – there are reports of such flares taking the form of a dermatitis with intense redness, stinging, and burning that can spread beyond the initial treatment area
• when prescribing a topical corticosteroid, consider the lowest potency needed
• advise patients on the amount of product to be applied; underuse can prolong treatment duration
• inform patients how long they should use a topical corticosteroid, especially on sensitive areas such as the face and genitals
• inform patients to return for medical advice if their skin condition worsens while using topical corticosteroid, and advise them when it would be appropriate to re-treat without a consultation
• for patients currently on long-term topical corticosteroid treatment, consider reducing potency or frequency of application (or both)
• be vigilant for the signs and symptoms of topical steroid withdrawal reactions and review the position statement from the National Eczema Society and the British Association of Dermatologists
• For advice to give to patients and carers, see the safety update here and the Patient Safety Leaflet on topical steroid withdrawal reactions developed by the MHRA

Choice of Preparation

Ointments are preferable to creams as they have a deeper, more prolonged emollient effect and increase the penetration of steroid. They are also less likely to cause irritation (as they do not contain preservatives) and/or sensitisation to the product.

Patients may prefer creams for application to the face and can be more suitable for moist or weeping lesions.

Dilution of topical corticosteroid preparations in emollient diluents to reduce steroid potency is not advised. The shelf life of the diluted product is significantly reduced leading to unsafe use past expiry date and waste of unused preparation. Diluted preparations are significantly more expensive (often greater than £100 per 100g). It is preferable to choose a ready-made product at the required steroid potency.

With antimicrobials / antifungals

The advantages of including other substances (such as antibacterials or antifungals) with steroids in topical preparations are debatable, but they may have a place where there is associated bacterial or fungal infection.

Suitable quantities of corticosteroid preparations

Topical corticosteroid preparations should be applied no more frequently than twice daily; once daily is often sufficient.

Topical corticosteroids should be spread thinly on the skin but in sufficient quantity to cover the affected areas. The length of cream or ointment expelled from a tube may be used to specify the quantity to be applied to a given area of skin. This length can be measured in terms of a fingertip unit (the distance from the tip of the adult index finger to the first crease). One fingertip unit (approximately 500 mg from a tube with a standard 5 mm diameter nozzle) is sufficient to cover an area that is twice that of the flat adult handprint (palm and fingers).

Systemic corticosteroids see section 6.3 Corticosteroids.

Mild

Hydrocortisone

• Ointment 0.5%, 1%, 2.5% (£4.98 = 30g x 1%)
• Cream 0.1%, 0.5%, 1%, 2.5% (£4.42 = 30g x 1%)

Indications

• Mild eczema
• Flexural, genital, and facial psoriasis

Dose

• Apply thinly once or twice daily

Notes

1. Hydrocortisone ointment and cream (1%) is available over the counter, at lower cost than a prescription, for the treatment of allergic contact dermatitis, irritant dermatitis, insect bite reactions and mild to moderate eczema. It cannot be sold for application to eyes/face, anogenital region, on broken or infected skin or for use in pregnancy or children under 10 years

Mild with antimicrobials / antifungals

Canesten HC

(Hydrocortisone 1% / clotrimazole 1%)

• Cream (£2.42 = 30g)

Indications

• Seborrhoeic dermatitis

Dose

• Apply thinly once or twice daily

Daktacort

(Hydrocortisone 1% / miconazole nitrate 2%)

• Cream (£2.49 = 30g)

Indications

• Seborrhoeic dermatitis

Dose

• Apply thinly once or twice daily

Fucidin H

(Hydrocortisone 1% / fucidic acid 2%)

• Cream (£6.02 = 30g)

Indications

• Infected eczema

Dose

• Apply thinly once or twice daily

Moderate

Eumovate

(Clobetasone butyrate 0.05%)

• Ointment (£1.86 = 30g)
• Cream (£1.86 = 30g)

Indications

• Moderate eczema
• Flexural, genital, and facial psoriasis

Dose

• Apply thinly once or twice daily

Notes

1. Eumovate cream can be sold over the counter (OTC), at lower cost than a prescription, for short-term symptomatic treatment and control of patches of eczema and dermatitis (but not seborrhoeic dermatitis) in adults and children over 12 years. However, the OTC license does not cover use on the face, groin, genital area or between the toes.

Betnovate RD

(Betamethasone valerate 0.025%)

• Ointment (£3.15 = 100g)
• Cream (£3.15 = 100g)

Indications

• Moderate eczema
• Flexural, genital, and facial psoriasis

Dose

• Apply thinly once or twice daily

Fludroxycortide

• Ointment 0.0125% (£5.99 = 60g)
• Cream 0.0125% (£12.49 = 60g)

Indications

• Inflammatory skin disorders such as eczemas

Dose

• Apply thinly 1–2 times daily

Fludroxycortide

• Tape, 4 micrograms/cm² (£28.95 = 7.5cm x 20cm)

Indications

• Chronic localised recalcitrant dermatoses (but not acute or weeping)

Dose

• Cut tape to fit lesion, apply to clean, dry skin shorn of hair, usually for 12 hours daily

Notes

1. May be useful to prevent picking of atopic eczema lesions and consequent damage to the skin

Moderate with antimicrobials / antifungals

Trimovate

(Combination of clobetasone butyrate 0.05% w/w, oxytetracycline 3.0% w/w, and nystatin 100,000 units per gram)

• Cream (£14.99 = 30g)

Indications

• Treatment and management of steroid responsive dermatoses where candidal or bacterial infection is present, suspected or likely to occur

Dose

• Apply thinly once or twice a day for up to 7 days

Potent

Betamethasone valerate

• Ointment 0.1% (£1.54 = 30g)
• Cream 0.1% (£2.62 = 30g)
• Scalp application (aqueous) 0.1% (£3.94 = 100ml)
• Cutaneous Foam 0.1% (£11.62 = 100g)

Indications

• Severe eczema
• Psoriasis

Dose

• Apply thinly once or twice daily

Notes

1. Not licensed for use in children under 1 year
2. Betamethasone cutaneous foam 0.1% is not licensed for use in children under 6 years

Synalar

(Fluocinolone acetonide 0.025%)

• Gel (£5.56 = 30g)

Indications

• Severe eczema

Dose

• Apply thinly once or twice daily

Metosyn

(Fluocinonide 0.05%)

• Ointment (£3.50 = 25g)
• Cream (£3.96 = 25g)

Indications

• Severe eczema

Dose

• Apply thinly once or twice times daily

Mometasone furoate

• Ointment 0.1% (£3.54 = 30g)
• Cream 0.1% (£3.57 = 30g)
• Scalp lotion 0.1% (£4.36 = 30ml)

Indications

• Severe eczema
• Psoriasis

Dose

• Apply thinly once or twice daily

Hydrocortisone butyrate

• Locoid ointment 0.1% (£4.93 = 100g)
• Locoid cream 0.1% (£4.93 = 100g)
• Locoid lipocream 0.1% (£5.17 = 100g)
• Locoid scalp lotion 0.1% (£6.83 = 100ml)
• Locoid Crelo lotion (emulsion) 0.1% (£5.91 = 100g)

Indications

• Severe eczema

Dose

• Apply thinly once or twice daily

Potent with antimicrobials / antifungals

Betamethasone and clioquinol

• Ointment (betamethasone 0.1%, clioquinol 3%) (£43.68 = 30g)
• Cream (betamethasone 0.1%, clioquinol 3%) (£40.82 = 30g)

Indications

• Infected eczema

Dose

• Apply thinly once or twice daily

Betamethasone and neomycin

• Ointment (betamethasone 0.1%, neomycin sulphate 0.5%) (£31.29 = 30g)
• Cream (betamethasone 0.1%, neomycin sulphate 0.5%) (£32.34 = 30g)

Indications

• Infected eczema

Dose

• Apply thinly once or twice daily

Fucibet

(Betamethasone 0.1% / fusidic acid 2%)

• Cream (£6.38 = 30g)

Indications

• Infected eczema

Dose

• Apply thinly once or twice daily

Potent with salicylic acid

Diprosalic

(Betamethasone 0.05% / salicylic acid 3%)

• Ointment (£9.14 = 100g)
• Scalp application (£10.10 = 100ml)

Indications

• Severe inflammatory skin disorders

Very Potent

Due to the risk of potential errors, clobetasol preparations should be prescribed by brand

If treatment with a local corticosteroid is clinically justified beyond 4 weeks, a less potent corticosteroid preparation should be considered.

Dermovate

(Clobetasol propionate 0.05%)

• Ointment (£2.69 = 30g)
• Cream (£2.69 = 30g)
• Scalp application (£10.42 = 100ml)

Indications

• Severe eczema
• Psoriasis

Dose

• Apply thinly 1–2 times daily for up to 4 weeks

Etrivex

(Clobetasol propionate 0.05%)

• Shampoo (£9.15 = 125ml)

Indications

• Scalp psoriasis

Dose

• Apply thinly once or twice daily (twice daily dose is unlicensed) for 2 weeks. Shampoo should be rinsed off after 15 minutes

Diflucortolone valerate

• Oily cream 0.3%

Indications

• Severe eczema
• Psoriasis

Dose

• Apply thinly once or twice daily for up to 2 weeks.