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Formulary
Page last updated:
8 October 2019
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13.4 Topical corticosteroids
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 & May 2024): topical corticosteroids: reminder of the possibility of severe side effects, including Topical Steroid Withdrawal Reactions
- Long-term continuous (generally 6 months or more) or inappropriate use of moderate to high potency topical corticosteroids can result in the development of rebound flares after stopping treatment, often referred to as ‘Topical Steroid Withdrawal Reactions’ (TSW). Symptoms include intense redness, stinging, and burning that can spread beyond the initial treatment area.
- TSW reactions are estimated to be rare and should be put into context of the millions of people that have benefitted from topical steroid treatment without experiencing any problems.
- When prescribing a topical corticosteroid:
- consider the lowest potency needed. Different potency products may be required for different body areas. Topical steroids will be labelled with their potencies to aid correct selection by patients requiring multiple products of different potency.
- advise on the amount of product to apply, how often, where to apply it and when to stop treatment (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
- If previous discontinuation of topical corticosteroids was associated with a suspected TSW reaction, consider alternative treatments.
- 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 TSW 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 and the Patient Safety Leaflet on TSW reactions developed by the MHRA. If appropriate, advise on symptoms of adrenal suppression.
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% (£5.16 = 1% x 30g)
- Cream 0.1%, 0.5%, 1%, 2.5% (£4.83 = 1% x 30g)
Indications
Dose
- Apply thinly once or twice daily
Notes
- 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
Dose
- Apply thinly once or twice daily
Fucidin H
(Hydrocortisone 1% / fucidic acid 2%)
- Cream (£6.02 = 30g)
Indications
Dose
- Apply thinly once or twice daily
Moderate
Eumovate
(Clobetasone butyrate 0.05%)
- Ointment (£1.86 = 30g)
- Cream (£1.86 = 30g)
Indications
Dose
- Apply thinly once or twice daily
Notes
- 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
Dose
- Apply thinly once or twice daily
Fludroxycortide
- Cream 0.0125% (£12.49 = 60g)
- Tape 4micrograms/cm2 (£32.52 = 7.5cm x 50cm)
Indications and dose
- Cream: Inflammatory skin disorders such as eczema
- Apply thinly once or twice daily
- Tape: Chronic localised recalcitrant dermatoses (but not acute or weeping) (specialist input)
- Cut tape to fit lesion and apply to clean, dry skin shorn of hair, usually for 12 hours daily
Notes
- Tape may be useful for hand eczema and localised skin cracks
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% (£1.60 = 30g)
- Cream 0.1% (£2.62 = 30g)
- Scalp application (aqueous) 0.1% (£3.94 = 100ml)
- Cutaneous Foam 0.1% (£11.62 = 100g)
Indications
Dose
- Apply thinly once or twice daily
Notes
- Not licensed for use in children under 1 year
- 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
Dose
- Apply thinly once or twice daily
Metosyn
(Fluocinonide 0.05%)
- Ointment (£13.15 = 100g)
- FAPG cream (£3.96 = 25g)
Indications
Dose
- Apply thinly once or twice times daily
Mometasone furoate
- Ointment 0.1% (£3.29 = 30g)
- Cream 0.1% (£3.56 = 30g)
- Scalp lotion 0.1% (£4.36 = 30ml)
Indications
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 topical emulsion 0.1% (£5.91 = 100g)
Indications
Dose
- Apply thinly once or twice daily
Potent with antimicrobials / antifungals
Betamethasone valerate and clioquinol
- Ointment (betamethasone 0.1% / clioquinol 3%) (£49.18 = 30g)
- Cream (betamethasone 0.1% / clioquinol 3%) (£46.84 = 30g)
Indications
Dose
- Apply thinly once or twice daily
Betamethasone and neomycin
- Ointment (betamethasone 0.1% / neomycin sulphate 0.5%) (£40.82 = 30g)
- Cream (betamethasone 0.1% / neomycin sulphate 0.5%) (£40.82 = 30g)
Indications
Dose
- Apply thinly once or twice daily
Fucibet
(Betamethasone valerate 0.1% / fusidic acid 2%)
- Cream (£6.38 = 30g)
Indications
Dose
- Apply thinly once or twice daily
Potent with salicylic acid
Diprosalic
- Ointment (betamethasone 0.05% / salicylic acid 3%) (£9.14 = 100g)
- Scalp application (betamethasone 0.05% / salicylic acid 2%) (£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
Dose
- Apply thinly 1–2 times daily for up to 4 weeks
Etrivex
(Clobetasol propionate 0.05%)
- Shampoo 500micrograms/g (£9.15 = 125ml)
Indications
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
Dose
- Apply thinly once or twice daily for up to 2 weeks.
