INTRODUCTION — Topical corticosteroids have a major role in the management of many inflammatory and autoimmune skin diseases (eg, atopic dermatitis, allergic contact dermatitis, radiation dermatitis, psoriasis, vitiligo, lichen planus, discoid lupus erythematosus). They exert anti-inflammatory, antiproliferative, and immunosuppressive effects through a variety of mechanisms [1,2].
This topic will discuss the general principles of selection and use of topical corticosteroids for skin diseases and the adverse effects of topical corticosteroids. The use of topical corticosteroids for specific skin diseases is discussed in detail in the relevant topic reviews. The use and adverse effects of intralesional and systemic corticosteroids are discussed separately.
MECHANISM OF ACTION — Once entered in the cell, topical corticosteroids bind to the cytoplasmic glucocorticoid receptor and are transported to the nucleus. The complex topical corticosteroid-glucocorticoid receptor binds to glucocorticoid response elements in the promoter region of a number of genes and modulates the transcription of a number of genes by inducing or inhibiting the transcription of specific mRNA and protein synthesis . Topical corticosteroids can also inhibit the activity of other transcription factors, including nuclear factor-kappa B (NFkB), activator protein 1 (AP-1), and nuclear factor of activated T cells (NFAT) .
These events lead to a series of local cellular effects, including the suppression of synthesis and release of prostaglandins and other inflammation mediators; release of the anti-inflammatory proteins (lipocortins, vasocortin, and vasoregulin) [5,6]; reduced release of inflammatory cytokines; inhibition of T cell activation; changes in the function of endothelial cells, granulocytes, mast cells, and Langerhans cells; and inhibition of mitotic activity of epidermal cells and dermal fibroblasts.
Lipocortins inhibit phospholipase A2 and block release of arachidonic acid and platelet-activating factor (PAF) from cell membranes, thus preventing the formation of potent inflammation mediators, such as prostaglandins and leukotrienes.
VEHICLES AND FORMULATIONS — Topical corticosteroids are available in a variety of vehicles and formulations. Vehicles are usually a combination of several chemicals, including emollients (eg, petrolatum, mineral oils, glycerin, lanolin, butyl stearate, cetyl alcohol), humectants (products that improve moisturization [eg, glycerin, polyethylene glycol]), emulsifying agents (eg, polysorbates), solvents (eg, polyethylene glycol, cetearyl alcohol, lanolin alcohol), penetration enhancers, and preservatives (eg, citric acid, potassium sorbate, parabens).
Vehicles should provide the rapid delivery of the drug to the stratum corneum and into the lower layers of the skin. They should be easy to apply and cosmetically acceptable. The vehicle must also provide a medium in which the drug remains stable. Oils act as emollients and, because of their occlusive properties, often enhance drug penetration. Liquids in vehicles evaporate, providing a cooling, soothing sensation, and may aide exudative lesions to dry. The optimal formulations for different body areas and lesions are shown in the table (table 1).
If the wrong formulation is used, the response to therapy may be delayed, inadequate, or, in some cases, worsened. As an example, the use of a corticosteroid gel on fissured hand eczema will cause increased pain and stinging due to the alcohol base of the gel. Treating a moist lesion with an ointment may cause folliculitis secondary to its occlusive properties.
Ointments — Ointments consist predominantly of water suspended in oil. This type of vehicle is an excellent lubricant, facilitates heat retention, decreases transepidermal water loss, provides enhanced medication absorption, and is semiocclusive. Ointments are generally the most potent formulations due to their occlusive effect, but patient acceptance and adherence to treatment may be low because they are greasy, sticky, and generally unsuitable for application to large body areas or to hairy areas. However, some patients prefer ointments for scalp dermatoses.
Creams — Creams are semisolid emulsions of 20 to 50 percent oil in water. They are cosmetically appealing and can be washed off with water. For the same topical corticosteroid, cream formulations are usually stronger than lotions but less potent than ointments.
Lotions — Lotions consist of suspensions or solutions of medication in water, alcohol, or other liquids. Thus, patients must shake the container before each application to receive the desired therapeutic concentration (and, therefore, the desired effect). Lotions (as well as foams and solutions) are especially useful in hairy areas and in conditions where large areas have to be treated. In addition, as lotions evaporate, they provide a cooling and drying effect, making them useful for treating moist dermatoses and/or pruritus. Like creams, lotions can be washed off with water.
Gels — Gels are systems of organic polymers (eg, methyl cellulose, alginates) with entrapped liquid; the liquid phase of gels is generally water but can also be alcohol or oil [7,8]. Gels are transparent, colorless, semisolid emulsions that liquefy on contact with the skin. They dry in a thin, greaseless, nonstaining film. Gel formulations combine the best therapeutic advantages of ointments with the best cosmetic advantages of creams, and they are cosmetically attractive to many patients . They are easily absorbed and are an efficient method for delivering topical corticosteroids to hair-bearing areas.
Foams — Foams are pressurized collections of gaseous bubbles in a matrix of liquid film. Foam preparations spread readily and are easier to apply than other preparations, particularly for inflamed skin and for scalp dermatoses. They are also often more cosmetically acceptable, as they disappear once applied to the skin, which can lead to higher compliance . Unlike other vehicles, foams depend on the vehicle delivery system for the physical delivery of the drug. Because of the complexities in designing vehicle delivery systems, foam preparations tend to be more expensive than other vehicles.
POTENCY — Topical corticosteroids induce cutaneous vasoconstriction commensurate with their potency [11-13]. The standard vasoconstriction assay provides potency measurements that correlate well with clinical anti-inflammatory efficacy . According to the United States classification system, topical corticosteroids can be subdivided into seven groups, with group 1 being the most potent and group 7 the least potent (table 2).
Factors that may increase topical corticosteroid potency include:
●Occlusive dressings promote cutaneous hydration and significantly increase absorption and potency . Occlusion can enhance topical corticosteroid potency by as much as 100-fold.
●Due to their occlusive properties, ointment preparations generally allow better percutaneous drug absorption and are, therefore, more potent than creams and lotions. One exception is the superpotent topical corticosteroid (eg, betamethasone dipropionate) that may be packaged in "optimized" cream vehicles (table 2).
Of note, increases in the concentration of a particular corticosteroid within a finite range in a defined vehicle may not enhance the potency or biologic activity of that particular drug .
PERCUTANEOUS ABSORPTION — The percutaneous absorption of topical corticosteroids depends on several factors :
●Type of corticosteroid and bioavailability
●Integrity of the skin barrier
●Use of occlusive dressings
●Frequency and duration of treatment
●Presence of inflammation
Systemic absorption is higher in areas of inflamed skin, compared with intact skin, as well as through the thin stratum corneum of infants' skin, compared with adult skin . Furthermore, anatomic regions with a thin epidermis are significantly more permeable to topical corticosteroids than thick-skinned areas . Regional differences in percutaneous absorption (percent of the total dose absorbed across the body) are as follows :
●Sole – 0.05 percent
●Palm – 0.1 percent
●Forearm – 1 percent
●Scalp – 3.5 percent
●Face – 7 percent
●Eyelids and genitalia – 30 percent
CORTICOSTEROID SELECTION AND ADMINISTRATION
General principles — The corticosteroid selection depends, to some extent, upon the condition being treated. In general, it is best to start with the lowest potency agents needed and use for as short a period of time as possible. Some general recommendations regarding selection of the optimal corticosteroid preparation include:
●Severe dermatoses – Super high-potency corticosteroids are generally used for severe dermatoses over nonfacial/nonintertriginous areas (eg, psoriasis, severe atopic dermatitis, severe contact dermatitis). They are especially useful over the palms and soles, which tend to resist topical corticosteroid penetration due to the thick stratum corneum.
●Nonfacial/nonintertriginous dermatoses – Medium- to high-potency strength preparations are appropriate for mild to moderate nonfacial/nonintertriginous dermatoses.
●Eyelid and genital dermatoses – Eyelid and genital dermatoses should be managed with low-potency topical corticosteroids for limited time periods.
●Large body areas – Low to medium strength preparations should be considered when large areas are treated because of the likelihood of systemic absorption .
Generic topical corticosteroids are effective for treating the majority of skin disorders seen in the primary care setting. Generic medications often have slightly less potency or less cosmetically appealing vehicles , but the substantial cost savings may negate any differences in efficacy or feel.
Mode of application — In addition to the type of lesion being treated and the base of the treatment vehicle, topical drug penetration into the skin is determined by the method of topical application. Emphasizing proper application is an essential part of patient education in the use of topical corticosteroids.
For optimal absorption, it is advised to apply topical corticosteroids to moist skin either immediately after bathing or after wet soaks ("soak and smear"). However, a small, randomized trial including 45 children with atopic dermatitis could not demonstrate that the application of topical corticosteroids to presoaked skin was more effective than application to dry skin .
Creams and ointments should be rubbed in until they disappear, since there is no advantage in leaving a thick layer on the skin. With foam vehicles, a small quantity (eg, the size of a golf ball) should be sprayed into the cap or on a saucer and then applied with a fingertip to the affected areas.
Occlusive dressings will enhance drug absorption, often by a factor of 10. The site of an application is also important as variations in the epidermal layer will alter the extent of drug absorption.
Amount and frequency of application — Topical corticosteroids are usually applied once or twice daily. However, twice-daily application may not be more effective than once daily, while increasing the systemic exposure to the drug and costs [23,24].
The amount of steroid used plays a great part in the efficacy of treatment but also in avoiding adverse effects from overuse. The fingertip unit (FTU), which is the amount of ointment or cream expressed from a tube with a 5 mm diameter nozzle and applied from the distal skin crease to the tip of the index finger of an adult (figure 1), is a convenient method to estimate the amount of a topical preparation to be used per application . One FTU is equal to 0.5 grams. The suggested dose of FTU is dependent upon the body region being treated. On average, the number of FTUs needed in certain body areas are as follows :
●Face and neck – 2.5
●Trunk (front or back) – 7
●One arm – 3
●One hand (dorsum or palm) – 0.5
●One leg – 6
●One foot – 2
When prescribing a medication, the amount to be dispensed needs to be considered carefully. An insufficient amount of medication used by the patient will most often lead to an inadequate therapeutic response. When considering the amount used per application, the number of applications to be given daily, and the duration of therapy, the prescription can be written so the patient will not run out of medication prematurely (table 3).
Treatment duration and tapering — The duration of daily use of super high-potency topical corticosteroids should not exceed four weeks if possible, although persistent lesions on small areas may be safely treated for a longer time . High-potency and medium-strength preparations rarely cause cutaneous side effects if used for less than six to eight weeks, although they can occur with shorter courses of treatment, especially on the face and intertriginous areas. Longer courses of therapy may be necessary for patients with chronic diseases, and these individuals should be closely monitored for the development of adverse effects. (See 'Adverse effects' below.)
Facial, intertriginous, and genital dermatoses should be treated for short courses of one to two weeks, preferably with low- to mid-potency topical corticosteroids, since these areas are most susceptible to corticosteroid-induced atrophy, telangiectasia, and acneiform eruption (see 'Cutaneous' below). Application to highly permeable areas also increases systemic absorption and is another reason to limit the duration of treatment in these areas. (See 'Systemic' below.)
Topical corticosteroids should be discontinued when the skin condition has resolved. Rebound flares can be avoided by tapering topical therapy with a gradual reduction of both potency and dosing frequency at two-week intervals. For some disorders, such as atopic dermatitis and psoriasis, intermittent therapy may be effective for maintaining long-term disease control. In randomized trials, twice-weekly application of topical corticosteroids (on two consecutive days, "weekend therapy") has been shown to reduce the risk of relapse in patients with atopic dermatitis once the underlying dermatosis is under control [28,29]. (See "Treatment of atopic dermatitis (eczema)", section on 'Maintenance and prevention of relapses'.)
Use in children — The use of lower-potency (groups 4 to 7 (table 2)) topical corticosteroids in children is generally safe when used for short durations and for appropriate inflammatory conditions . Children under age 12 years typically should not use potent or superpotent topical corticosteroids. An exception can be made for very severe inflammatory dermatoses (eg, psoriasis, severe atopic dermatitis), for which short courses (up to two weeks) of more potent (groups 1 to 3) topical corticosteroids may be warranted . (See "Psoriasis in children: Management of chronic plaque psoriasis", section on 'Topical corticosteroids' and "Treatment of atopic dermatitis (eczema)", section on 'Topical corticosteroids'.)
To minimize the risk of side effects, high-potency corticosteroids should not be used on the face, intertriginous areas, or other thin-skinned, highly penetrable areas (eg, the perineum, axillae) in children [32-34]. In addition, high-potency corticosteroids should ideally be used only once a day and should not be administered for longer than two weeks . Even low-potency topical corticosteroids can cause side effects in children when used for extended periods of time. (See 'Adverse effects' below.)
Use during pregnancy or lactation — Data on the safety of topical corticosteroids in pregnancy are limited. Based on the available evidence, the use of low- to mid-potency topical corticosteroids does not seem to increase the risk of adverse outcomes for the mother and the fetus, including preterm delivery, congenital anomalies, and low birth weight [17,36,37]. Because an association between prolonged maternal use of potent topical corticosteroids and low birth weight cannot be excluded with certainty, it is prudent that pregnant women who need treatment with topical corticosteroids use low- or mid-potency topical corticosteroids rather than potent or superpotent preparations (table 2). If potent or superpotent topical corticosteroids are needed, they should be used for a short time, the amount used should be kept to a minimum, and fetal growth should be monitored [17,36]. (See "Recognition and management of allergic disease during pregnancy".)
In a 2015 Cochrane meta-analysis of 14 observational studies with over 1,600,000 pregnancies evaluated, stratified analysis of seven studies found no causal associations between maternal exposure to topical corticosteroids of any potency and congenital abnormalities, including orofacial clefts and hypospadias, preterm delivery, low birth weight, or low Apgar score, compared with no exposure . However, three individual studies included in the analysis suggested a relationship between low birth weight and potency and dose of topical corticosteroids [38,39]. In particular, one cohort study found that the risk of low birth weight was significantly increased only when the amount of potent or very potent corticosteroids used during the entire pregnancy exceeded 300 grams (risk ratio [RR] 7.7, 95% CI 1.5-40.1) .
There are no studies assessing the safety of topical corticosteroid use during lactation. It is recommended that the topical treatment in the nipple region be applied after nursing the child, to allow the drug to be absorbed before the next feeding, and that the nipple area be gently cleaned of the remaining drug before nursing .
ADVERSE EFFECTS — Topical corticosteroids are safer than systemic glucocorticoids. Nevertheless, cutaneous and systemic side effects can occur, particularly with superpotent and potent drugs or extensive use of lower-potency agents with or without occlusion.
Cutaneous — A number of cutaneous effects may occur with topical corticosteroid use [41-43]:
●Atrophy, telangiectasia, striae – Superpotent and potent topical corticosteroids may induce atrophy, telangiectasia, and striae as early as two to three weeks following daily application (picture 1A-B) [44,45]. Intertriginous and thin-skinned, highly penetrable areas (eg, eyelid, face in general, genitals) are particularly susceptible to atrophy, which usually recovers within weeks to months if therapy is discontinued as soon as atrophic change occurs. A small study of 20 patients with psoriasis found that limited use (to skin lesions less than 2x2 cm) of fluticasone propionate ointment (a group 3 agent) for 10 weeks on the face and intertriginous areas did not cause atrophy or telangiectasia [46-48]. (See "Striae distensae (stretch marks)".)
●Acneiform eruption – Prolonged use of topical corticosteroids may induce an acneiform eruption that resolves with discontinuance of corticosteroid treatment (picture 2A-B). Chronic application of topical corticosteroids to the face may also cause a dry, scaly eruption with scattered, follicular pustules around the mouth (perioral dermatitis), and use of potent topical corticosteroids on the face can cause a facial eruption that is indistinguishable from rosacea  (see "Rosacea: Pathogenesis, clinical features, and diagnosis"). Treatment includes discontinuation of steroid therapy with a gradual taper.
●Withdrawal syndrome – Withdrawal of topical corticosteroids after prolonged use, especially on the face or genitals, may induce a varying constellation of signs and symptoms including erythema, burning or stinging sensation, pruritus, pain, and facial hot flashes . These symptoms occur days to weeks after steroid discontinuation.
●Allergic sensitization – Allergic sensitization to topical corticosteroid preparations can occur . Vehicles or preservatives are most often the sensitizing agents, although contact allergy against the steroid moiety itself is possible [51,52]. Topical glucocorticoid-induced contact allergy should be suspected in patients with chronic dermatoses that appear to be exacerbated by therapy. Patch testing is useful for determining whether contact dermatitis associated with a topical corticosteroid is secondary to the vehicle or to the corticosteroid itself . Cross-reactions between different topical corticosteroids are determined by their chemical structure . The classification of topical corticosteroids (class A through D) by pattern of cross-reactivity is illustrated in the table (figure 2). Cross-reactivity between groups is not uncommon. Class C topical corticosteroids have the lowest rate of allergenicity. Referral for patch testing may be indicated in patients whose history and examination are suggestive of a contact dermatitis to topical corticosteroids .
●Masking of dermatophyte infection – The inappropriate use of topical corticosteroids can worsen or mask the typical clinical features of the appearance of dermatophyte infections ("tinea incognito"). (See "Dermatophyte (tinea) infections", section on 'Treatment principles'.)
●Other – Other cutaneous side effects of topical corticosteroids include purpura, changes in pigmentation, and hypertrichosis .
Systemic — Prolonged use of topical corticosteroids, particularly super high-potency and high-potency corticosteroids (groups 1 to 3 (table 2)), can cause hypothalamic-pituitary axis (HPA) suppression, hyperglycemia, and glaucoma or posterior subcapsular cataracts. No effect of topical corticosteroids on bone mineral density has been reported [55-57]:
●Hypothalamic-pituitary axis suppression – Factors that predispose to HPA suppression include use of high-potency corticosteroids, chronic use, application to highly permeable areas, treatment of large areas, occlusion, altered skin barrier (common in the conditions for which these medications are prescribed), and young age. Routine use of even mild corticosteroids in young children can cause HPA suppression:
•In a meta-analysis of 12 studies including 522 children (age 3 months to 18 years) with atopic dermatitis treated with topical corticosteroids for two to four weeks, HPA suppression was observed in 20 cases (3.8 percent, 95% CI 2.4-5.8) . The rates observed in children using low-, medium-, or high-potency corticosteroids were 2, 3.1, and 6.6 percent, respectively, although the difference among rates was not statistically significant.
•Similar results were found in a meta-analysis of randomized and observational studies in adults that showed 4.7 percent (95% CI 1.1-18.5) of patients had HPA suppression following topical corticosteroid use . Compared with nonusers, patients using topical corticosteroids for the treatment for psoriasis, atopic dermatitis, or lichen planus had a nearly ninefold increased risk of HPA suppression (risk ratio [RR] 8.9, 95% CI 2.4-27.9).
●Hyperglycemia – Hyperglycemia and unmasking of latent diabetes mellitus can also occur . A meta-analysis of four case-control studies found a modest increase in risk of type 2 diabetes mellitus associated with topical corticosteroid use (odds ratio [OR] 1.24, 95% CI 1.15-1.34) .
●Glaucoma/cataract – Rarely, chronic periorbital application of high-potency topical corticosteroids may induce glaucoma or posterior subcapsular cataracts [61-63].
Tachyphylaxis — Tachyphylaxis has been associated with topical corticosteroid use based upon experimental data showing reductions in corticosteroid-induced vasoconstriction, antiproliferative effects, and inhibition of histamine release following repeated applications [64-66]. However, this phenomenon has not been confirmed in clinical settings [67,68]. In one study of 32 patients with psoriasis that specifically assessed for tachyphylaxis, no evidence for this phenomenon was observed during daily treatment with a high-potency topical corticosteroid for three months . It has been proposed that patients' lack of adherence to treatment over time may account for apparent reductions in topical corticosteroid efficacy.
PITFALLS OF TREATMENT — The most common treatment errors are:
●Suboptimal medication use related to either too low or too high medication strength, improper vehicle, or insufficient dose
●Lack of patient adherence as a result of inadequate patient education or adverse drug events
●The use of combination steroid/antifungal formulations
●Disregard for medication costs
Suboptimal medication use — The most frequent example of suboptimal medication use is the patient with extensive, inflammatory disease given either too low of a potency or too small of a supply to be effective. For instance, hydrocortisone cream 1% is not strong enough to treat most cases of moderate inflammation. Similarly, prescribing an amount of an adequate potency topical corticosteroid sufficient to treat the affected area for only three days will likely result in treatment failure. (See "Management of allergic contact dermatitis", section on 'Pharmacologic treatment'.)
Poor adherence/incorrect use — Proper patient adherence to the prescribed treatment includes receiving thorough patient education about the nature of the problem and proper use of the medication. Specific reasons for inadequate application of treatment include financial considerations, concerns about medication side effects, patient dislike of topical preparations, and insufficient time for clinicians to educate patients about skin care.
Topical corticosteroid phobia, defined as a concern or fear about using topical corticosteroids, is common, with a prevalence among patients with atopic dermatitis and caregivers ranging from 20 to over 80 percent worldwide [69,70].
Patients with chronic conditions, such as psoriasis or atopic dermatitis, must be educated about the natural history of exacerbations and remissions, as well as the time needed to see any improvement after initiating the designated pharmacotherapy.
Combination antifungal/topical corticosteroid products — Many clinicians will prescribe a combination antifungal/topical steroid product to a patient with a skin lesion because they are unsure if the diagnosis is fungal or inflammatory dermatitis. Usually, a simple potassium hydroxide (KOH) scraping can differentiate the two conditions, enabling the clinician to prescribe one medication, rather than two. (See "Office-based dermatologic diagnostic procedures", section on 'Potassium hydroxide preparation'.)
Two problems with these combination products are:
●They are expensive compared with generic topical corticosteroids and over-the-counter topical antifungal products alone. In one study, nondermatologists were more likely than dermatologists to prescribe combination antifungal/topical steroid products for the treatment of common fungal skin infections (34 versus 5 percent), costing an additional USD $10 to $25 million as a whole to the health care system .
●The steroid preparation in the combination products may be potent. If patients are using the potent steroid on a simple fungal infection, they risk incomplete resolution of the fungal infection as well as thinning of the skin if used for a prolonged period of time [72,73].
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Topical corticosteroid medicines (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Indications – Due to their anti-inflammatory, antiproliferative, and immunosuppressive effects, topical corticosteroids have a major role in the management of many inflammatory and autoimmune skin diseases (eg, atopic dermatitis, allergic contact dermatitis, radiation dermatitis, psoriasis, vitiligo, lichen planus, discoid lupus erythematosus).
●Vehicles and formulations – Topical medications are available in a variety of vehicles, including ointments, creams, lotions, solutions, gels, and foams. Factors such as lesion quality (eg, moist versus dry) and location (eg, hairy versus nonhairy skin) play an important role in vehicle selection (table 1). Care should be taken to select the most appropriate vehicle to maximize effectiveness and compliance. (See 'Vehicles and formulations' above.)
●Potency – Topical corticosteroids are classified into seven groups according to potency (table 2). The potency of a drug is influenced by the vehicle. In the clinical setting, the use of occlusion can increase the potency of topical corticosteroids. (See 'Potency' above.)
●Selection – The corticosteroid selection depends on the condition being treated. Super high-potency corticosteroids are generally used for severe dermatoses over nonfacial/nonintertriginous areas, whereas facial and intertriginous areas should be managed with low- to medium-potency topical corticosteroids for a limited period of time. (See 'General principles' above.)
●Amount and frequency of application – The fingertip unit (FTU; ie, the amount of ointment or cream expressed from a tube with a 5 mm diameter nozzle, applied from the distal skin crease to the tip of the index finger of an adult) is a convenient method to estimate the amount of a topical preparation to be used per application. Topical corticosteroids are usually applied once or twice daily. (See 'Amount and frequency of application' above.)
●Adverse effects – Topical corticosteroids are safer than systemic glucocorticoids. Nevertheless, cutaneous and systemic side effects can occur, particularly with superpotent and potent drugs or extensive use of lower-potency agents with or without occlusion (see 'Adverse effects' above):
•Cutaneous – Cutaneous atrophy, telangiectasias, and striae (picture 1A-B) are potential adverse effects of topical corticosteroid therapy and are more likely to occur with the use of higher-potency agents. In general, the use of super high-potency topical corticosteroids should be restricted to highly inflammatory dermatoses on the scalp, trunk, or extremities. Facial or intertriginous areas are most likely to develop signs of cutaneous atrophy. Other cutaneous adverse effects include acneiform eruptions (picture 2A-B), purpura, hypopigmentation, and glaucoma. (See 'Cutaneous' above.)
•Systemic – Hypothalamic-pituitary axis suppression may occur with prolonged use of high-potency corticosteroids, application to highly permeable areas, treatment of large areas, occlusion, and impaired skin barrier. Hyperglycemia and unmasking of latent diabetes mellitus can also occur. (See 'Systemic' above.)
●Treatment pitfalls – Suboptimal medication use due to improper prescribing or poor communication with patients can result in treatment failure. When prescribing topical corticosteroids, care should be taken to ensure that the quantity prescribed is sufficient to cover the entire treatment area for the duration of treatment (table 3). (See 'Pitfalls of treatment' above.)
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