Safety of topical corticosteroids

Topical corticosteroids generally have good safety profiles. Despite this, patients, parents and carers often have concerns about using topical corticosteroids, which can lead to underuse and treatment failure. It is important to explain to patients, parents and carers that:

• topical treatments are generally considered safer than systemic (oral) treatments
• being too cautious about using topical corticosteroids can result in inadequate treatment of the skin condition, resulting in stronger drugs (eg oral drugs) being required for a longer time
• topical corticosteroids can be safely used for long periods if the appropriate formulation and concentration are correctly applied
• side effects (eg skin atrophy, systemic adverse effects) are uncommon, but are more likely to occur with inappropriate use of long-term or high-dose treatment without adequate clinical supervision.

Parents and carers are often particularly concerned about using topical corticosteroids in their children, including concern about potential effects on wellbeing and development. Effective treatment of chronic skin conditions can promote wellbeing and development, which is particularly important as the child nears puberty. The harms of a poorly controlled chronic skin condition (eg atopic dermatitis) outweigh the harms of topical corticosteroids. Position statements and fact sheets available from the Australasian College of Dermatologists website provide useful information about topical corticosteroids in paediatric dermatitis for health professionals, parents, carers and patients.

The application of some formulations of topical corticosteroid may cause temporary symptoms (eg creams can briefly cause stinging, ointments can briefly worsen itching in summer). Preservatives present in some formulations can increase the risk of irritation, stinging and contact allergy.

Short courses of treatment are usually not associated with any significant side effects. Longer courses of treatment with more potent corticosteroids can be associated with:

• skin thinning (atrophy)
• stretch marks (striae) in armpits or groin area
• enlarged or broken capillaries (telangiectasia)
• easy bruising and tearing of the skin
• localised increased hair thickness and length (hypertrichosis)
• acne-like changes
• colour change of the skin
• periorificial dermatitis
• steroid rosacea
• pustular psoriasis.

Note that the skin disease being treated can also produce changes in the appearance of the skin.

It is unclear whether exposure of topical corticosteroids to the eyes can lead to eye problems such as cataracts and glaucoma; it is sensible to keep the use of topical corticosteroids around the eye area to a minimum.

Red skin syndrome (sometimes inappropriately referred to as ‘topical corticosteroid withdrawal’) is a rare adverse reaction resulting from inappropriate topical corticosteroid use in some conditions (eg periorificial dermatitis, rosacea, some psoriasis conditions) and when treating certain areas of the body (eg genital area). Symptoms include papulopustular rashes and red burning skin. While these symptoms can be a rare adverse effect of the topical corticosteroid, they can also be associated with an exacerbation of the original skin condition.

Monitoring for systemic side effects of topical corticosteroids is not usually necessary because little, if any, corticosteroid is absorbed through the skin into the body. Cushing syndrome is rarely reported with topical corticosteroid use, and only occurs after long-term use of large quantities of topical corticosteroid (eg more than 50 g of clobetasol propionate or more than 500 g of hydrocortisone per week).