Steroids and other topical medications
A lot of people are wary of steroids. If used properly, though, they rarely lead to side effects. And they are only used for acute flare-ups, not for long-term treatment. Preventive intermittent treatment with topical corticosteroids can help with frequent flare-ups.
In mild eczema, a special skin care routine may be enough to keep the condition at bay. If the skin is inflamed and itchy, a topical corticosteroid ointment or cream is used on the rash too. Topical means “applied to the skin.” These products can effectively reduce the itching and inflammation. They are used until the symptoms go away. If for some reason steroids shouldn’t be used, the medications pimecrolimus or tacrolimus can be considered. These belong to a group of medications called calcineurin inhibitors. They are used if, for instance, sensitive areas such as the face or genitals are affected.
What’s the difference between the various topical corticosteroids?
There are more than 30 different topical steroids for the treatment of eczema. There are big differences between them in terms of the strength of their effect (their potency). They can generally be divided up into four groups based on their potency:
- Low-potency corticosteroids, e.g. hydrocortisone and prednisolone
- Moderate-potency corticosteroids like prednicarbate, methylprednisolone and triamcinolone.
- High-potency corticosteroids such as betamethasone and mometasone.
- Ultra-high-potency corticosteroids, such as clobetasol
How well a steroid product works will depend on its active ingredient (the drug in it)and various other factors, including the following:
- The dosage used
- The area of skin that it is applied to Thinner skin absorbs more steroids than thicker skin does. This means that, for instance, the skin on the palms of your hands and soles of your feet absorbs a relatively small amount of the steroid medication, whereas the skin on your face and scalp absorbs quite a lot more. The skin on your eyelids and genitals is particularly sensitive.
- The type of product: Steroid ointments are stronger than steroid creams or lotions. This is because steroids are more easily absorbed by the skin when applied as an ointment.
- How it is applied: Topical corticosteroids work better when applied to wet skin – for instance after getting out of the bath – than when applied to dry skin. The effect is even stronger if the skin is covered up with a bandage or wet wrap after the steroid medication is applied. This greatly increases the amount of steroids that are absorbed.
Topical corticosteroids have to be prescribed by a doctor, with one exception: Low-dose hydrocortisone. Ointments or creams containing low doses of hydrocortisone are available from pharmacies even without a prescription. It’s best to talk to your doctor about which topical steroid to use and how to apply it.
Which topical steroid is most suitable?
The choice of topical steroid will depend on the person’s age, how severe the eczema is, and which area of the body is affected. Low-potency and moderate-potency corticosteroids are usually enough to keep eczema at bay. Generally speaking,
- topical corticosteroids of low to moderate potency are particularly suitable for the treatment of eczema in areas where the skin is sensitive and thin. These include the face, the back of the knees, the insides of the elbows, the groin area and the armpits.
- High-potency and ultra-high-potency corticosteroids are used for the treatment of severe eczema on the palms of the hands and soles of the feet, or for the treatment of eczema on very thick skin.
- High-potency and ultra-high-potency corticosteroids shouldn’t be used on rashes that cover a large area of skin.
- Very sensitive areas such as your neck or genitals should only be treated with low-potency corticosteroids.
It is also possible to switch between products of different strengths. For example, some doctors recommend starting treatment with a high-potency corticosteroid in order to get the flare-up under control as quickly as possible, and then switching to a weaker corticosteroid after a few days. Others prefer to start with a low-potency corticosteroid and only change to a stronger one if the first medication doesn’t work well enough. It’s best to talk with your doctor about your preferred strategy.
How are steroids used?
Corticosteroid ointments or creams are applied to the affected areas of skin one or two times a day. A lot of people do this in the morning and/or in the evening. This treatment is continued until the inflammation has gone away. It’s hard to say exactly how long that will take. The treatment can last anywhere between a few days and six weeks. This will depend on the strength of the corticosteroid and the affected areas of skin. Steroid medication generally shouldn’t be applied to sensitive areas of the body for longer than a few days.
It is important to continue using moisturizing products on the skin during treatment with steroids. Doctors recommend waiting about 15 minutes between applying a topical corticosteroid and applying the moisturizing product. This allows the steroid to be absorbed properly. According to current knowledge, it doesn’t matter which order you apply them in.
If the eczema is severe, you can apply the topical corticosteroid first and then cover the affected area with a wet wrap in order to increase the effect of the medication. But there is no good research on the benefits and drawbacks of this approach. Some studies have shown that it is associated with a higher risk of side effects, such as inflamed hair follicles and skin infections. Using wet wraps can also cause greater amounts of steroids to enter your bloodstream. So it’s important to talk to a doctor about whether to use this approach beforehand.
The right amount
How much corticosteroid ointment or cream you should use will depend on how big the affected area of skin is. A unit known as the “fingertip unit” (FTU) is used to describe the amount needed. 1 FTU is the amount of ointment or cream that is squeezed out of a tube along the last section of an adult’s finger (see illustration). This is about 0.5 grams.
1 fingertip unit (1 FTU)
Depending on the area of skin, the following amounts (in FTU) are recommended:
Avoiding side effects
People are often wary of using steroids because they have heard a lot of bad things about the side effects. In the past, many people who were treated with steroids experienced side effects. This is because steroid medications were often used for too long, too often, and in too high doses.
Most people who have eczema, or the parents of children with eczema, are usually mainly concerned that steroids will make their skin thinner. But studies comparing different treatments haven’t found any evidence that the skin becomes permanently thinner if steroids are only used carefully to treat flare-ups. The skin may indeed get thinner when using topical corticosteroids, even if they are only used for a short while, but it returns to normal again afterwards.
Other possible side effects include small changes in pigmentation (white spots), and temporary blisters. Another possible side effect is known as telangiectasia. This is the medical term for small dilated capillaries that look a bit like spider webs on the skin. Topical steroids may also increase the likelihood of skin infections because steroids inhibit the immune function of the skin.
In order to avoid side effects as much as possible, it’s important to choose a steroid ointment or cream that’s suitable for the severity of eczema and the affected area of skin. For longer-term treatment, it is best to use a topical steroid that is as strong as necessary and as mild as possible. Applying a thin layer just once a day is often enough. According to current research, steroid creams or ointments aren’t more effective when used twice a day – or at least the stronger products aren’t.
It’s also important to use topical steroids long enough when treating flare-ups. In other words, until the skin stops itching and the inflammation has gone away. If you stop the treatment too soon, the rash might return. Then you might end up using more steroid medication overall than if you had continued using it for long enough in the first place.
Some people are afraid of severe side effects that affect the whole body. But when steroids are applied to the skin in the form of ointments or creams, a far smaller amount of the drug enters the body than when swallowed in the form of tablets. So if topical steroids are used properly, the risk of severe side effects is very small.
Are steroids safe in pregnancy?
A group of researchers wanted to find out how safe it is for pregnant women to use corticosteroid creams and ointments. They analyzed the data of more than a million women and their babies. When they compared pregnancy complications in women who used low-potency topical corticosteroids with the complications in women who used moderate-potency creams, no difference was found. They looked at things like congenital defects, birth weight, and which week of pregnancy the baby was born in. The research suggested that babies had a lower birth weight if their mothers used high-potency or ultra-high-potency topical corticosteroids – particularly if they used them in larger amounts. But they didn't find any other links between the different strengths of medication and complications.
People who have moderate to severe eczema with frequent flare-ups may benefit from using topical corticosteroids intermittently on only two days per week, while still using moisturizing products on a daily basis. This approach can significantly reduce the frequency of flare-ups. The steroid cream can either be applied on two consecutive days (e.g. as a "weekend therapy") or with a break between the two days – for instance, on Mondays and Thursdays.
Because eczema sometimes gets better over time, it's a good idea to stop using the corticosteroid after a while in order to see whether you still need it.
Pimecrolimus and tacrolimus
Two other medications have been approved in Germany for the treatment of eczema: Pimecrolimus (trade name: Elidel) and tacrolimus (trade names: Protopic, Prograf, Advagraf). These both belong to a group of drugs called calcineurin inhibitors. Also known as immunomodulators, they inhibit specific substances that play a role in inflammation. A thin layer of pimecrolimus or tacrolimus is applied to inflamed areas of skin twice a day. Pimecrolimus has been approved in the form of a 1% cream. Tacrolimus comes in two forms: a 0.03% ointment and a 0.1% ointment.
When can pimecrolimus or tacrolimus be used?
Pimecrolimus has been approved for the treatment of mild to moderate eczema, and tacrolimus has been approved for the treatment of moderate to severe eczema. They can only be used in certain situations. For instance, they can be prescribed:
- if steroids haven't led to a big enough improvement.
- for the treatment of particularly sensitive areas such as the genitals or face, and especially the eyelids.
- if steroids aren't well tolerated.
Creams and ointments with pimecrolimus and 0.03% tacrolimus can be used in children aged two and over, as well as in teenagers and adults. Those with 0.1% tacrolimus can only be prescribed for people aged 16 and over.
If treatment with these calcineurin inhibitors is successful, they can also be used intermittently to prevent further flare-ups. This involves applying them to the affected areas of skin on two days per week (once on each day). You should wait a few days between applications. For instance, pimecrolimus or tacrolimus could be applied once on Mondays and once on Thursdays.
How effective are pimecrolimus and tacrolimus, and what side effects might they have?
Research has shown that pimecrolimus and tacrolimus can relieve eczema flare-ups. But they aren't more effective than steroid creams of similar strength. Both medications can have side effects too. Burning, redness and itching may occur, particularly in the first few days of treatment.
You should stop using pimecrolimus and tacrolimus if the skin becomes infected.
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