Reasons to Limit Topical Steroid Use

https://www.dermnetnz.org/topics/treatment-of-atopic-dermatitis/

Rash on the Face/ genitals/ skin folds/infants

  • thinnest skin is found on the face (particularly the eyelids), genitals, body folds and the skin of infants. These areas absorb topical steroids very readily and are more prone to local side effects from them.

Large surface area

  • Systemic absorption and adrenal suppression is a concern if large amounts of potent topical steroids (e.g. more than 100g/week) are used over a long period of time (months).

Alteration of normal skin Microbiome

Mild eczema is likely to respond to low potency topical steroids within a few days, often with complete clearance of eczema within one or two weeks.

Moderate eczema may require more potent topical steroids for at least two weeks before improving and may require several weeks of treatment before clearing. 

Severe eczema may show only partial improvement with potent topical steroids alone even after several months of use.

 Eczema tends to be persistent and will have to use topical steroids on and off indefinitely which increases the risk of tachyphylaxis   

  • The intermittent use of topical steroids works very well for mild eczema, which responds within a week or two to relatively weak steroids and clear skin can often be maintained with emollients alone. If the eczema flares, the same topical steroid can be used again.
  • Moderate and severe eczema are more difficult to manage. Eczema may not have completely cleared with a potent topical steroid after three to four weeks. This can be managed by gradually reducing the number of days the stronger topical steroid is used, for example using a potent topical steroid at weekends and an emollient on weekdays.
  • If tachyphylaxis occurs, treatment needs to be tailored to the individual patient. Changing to a different topical steroid of the same strength can be helpful. Treatment of infection, if present, may again make the topical steroid effective. A stronger topical steroid or an additional treatment such as phototherapy may be required.