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Get your #dermatology jokes out now, because this is a #tweetorial/#medthread on....


Read on for tips on how to prescribe them, which one to choose, when does it matter, etc.

#MedEd #FOAMed #dermtwitter #medtwitter #dermatologia pc:@dermnetnz
Truly the workhorse of the #dermatologist's medicine chest, topical steroids are great for a multitude of reasons:
- Delivery straight to the organ of interest
- Systemic absorption is usually minimal
- Can be cheap (usually)

What on skin exam best suggests steroids may work?
Erythema is a great indicator that there is inflammation. As such, topical steroids may be a good treatment option. However, there are some reasons NOT to use topical steroids. For example, if the rash is infectious (eg: tinea in photo1, herpes in photo2), steroids = no bueno.
Another reason not to use topical steroids might be if the process is too deep. For example, while topical steroids work well in patch/plaque stage mycosis fungoides (photo 1), it really doesn't touch tumor stage MF (photo 2).
So how do you pick the right steroid? First, we should discuss how they're categorized. There are 7 classes. Class 1 is strongest, class 7 is weakest (eg: what you can get OTC).

Thanks to @NPF for the steroid chart!
You might notice that some steroids appear in multiple categories (eg: betamethasone dipropionate is in both class 1 and class 2). That's because the strength of the steroid depends on the concentration AND the vehicle.

Ointments >> Creams >> Lotions
Unfortunately, this is usually inversely related to comfort. Patients tend to like lotions >> creams >> ointments. That's because ointments feel like vaseline (and look like it too), whereas creams are white and "rub into" the skin easier.
So which one should you choose? Another point to consider is the body site involved. A patient's face, armpits, & groin have the thinnest skin, whereas the scalp, hands, & feet have the thickest. So we generally will prescribe weaker steroids (class 6/7) for the thinner areas.
A few examples of how I might prescribe these:

- Mild seborrheic dermatitis on the face: (class 6-7)
- Psoriasis in the scalp: (class 1-2)
- Full body rash, super symptomatic (class 1-2, avoiding the thin areas).
- Full body rash, annoying, but pt doing ok (class 3-4).

In general, you can use all these steroids BID for 2 weeks max. After that, we advise a 2 week break. Another way to think about it is that you should NOT use it as much as you're using it. One area I might be more conservative are areas w/ thinner skin (eg: 1 week instead).
We limit steroid use because with excessive use, side effects occur, like skin thinning, purpura, & stretch marks. It's really important to counsel carefully, otherwise patients will use them forever! Steroids can also cause other skin disease, like perioral derm (photo3)!
So how do you realistically do this? My tip is to pick your favorite class 1-2, class 3-4, & class 6-7 steroid. That way, based on the exam, you always have one to use. My go to steroids:
Class 1-2: betamethasone dipropionate
Class 3-4: triamcinolone
Class 6-7: hydrocortisone
These choices change depending on a variety of factors. If insurance covers one versus another, I'll choose the cheaper option. Also, if it's for a hair-bearing area, I'll use a lotion or a liquid/foam instead. If the patient needs A LOT, triamcinolone comes in a 1lb jar!
A few other points:
- Try desoximetasone for patients that get allergies to other steroids. That one is in its own class (allergen wise), so it doesn't cross react.
- Don't get it in the eyes!
- There are steroids sparing agents that can be tried too. Ask a #derm for help!
One more tip. Make sure you prescribe enough! If the rash is extensive, and you prescribe "1 tube," the pharmacy will dispense 15 g usually. That's less than a travel sized toothpaste! For full body, I'll use the 1lb jar (454 g), or at least 2 of the largest sized tubes!
And don't forget - even infectious things may get better with topical steroids at first (because you're treating that inflammation). So be careful, and perhaps if it scales, always consider evaluating for a fungal process.
To recap:
- Topical steroids are a great option for inflammatory skin disease.
- Avoid with suspected infections and if the process is too deep.
- Pick your favorite from each category (strong, medium, mild) of potency.
- Limit to BID x 2 weeks max. You need to take breaks!
One last thing. I made a topical steroids cheat sheet, which I've shared with medicine residents. I've added it here in case you find it helpful!

Remember - these are generic tips for steroid use; every patient is different! #dermatologists are here to help!
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