Synopsis
Choose a topical corticosteroid by diagnosis, inflammatory severity, anatomical site, age, surface area and vehicle, prescribe a measurable course, and prevent infection masking, atrophy, systemic absorption and withdrawal-related harm.
- Confirm an inflammatory corticosteroid-responsive diagnosis before prescribing; tinea, scabies, HSV, acne, rosacea and malignancy can worsen or become obscured under steroid.
- Potency follows both inflammation and site: palms, soles and thick plaques may need more potency than face, eyelids, folds, genital skin or infant skin.
- Mild, moderate, potent and very potent are pharmacological classes, not instructions to use the strongest available product until redness fades.
- Ointment suits dry, thick or lichenified disease and contains fewer preservatives; cream is less occlusive and often more acceptable for moist, weeping or flexural areas.
- Lotion, gel, foam or solution can reach hairy scalp and large areas more easily, but alcohol-containing products sting fissured skin and aerosols bring fire or inhalation concerns.
- One adult fingertip unit is about 0.5 g and covers roughly two adult handprint areas; prescribe enough for body area and duration and verify the product actually used.
- Apply to active disease, usually once daily when supported by the product and condition pathway; more frequent use rarely adds benefit but increases burden and exposure.
- Occlusion, nappies, wraps, thin skin, broken barrier and extensive area markedly increase absorption and can convert an apparently local treatment into systemic exposure.
- A short correctly selected course usually causes less harm than persistent undertreated inflammation; safety comes from explicit site, quantity, duration and review rather than vague steroid avoidance.
- Topical steroid withdrawal reactions are uncommon and mainly reported after prolonged frequent use of moderate or stronger products, especially on face or genital skin; do not confuse them with ordinary relapse, infection or contact allergy.
Key red flags
Systemic illness, painful vesicles or erosions, purpura, rapidly advancing infection, visual symptoms after periocular use, marked skin atrophy, growth faltering, Cushingoid change, prolonged use over a large or occluded area, or systemic symptoms after sudden cessation requires urgent clinical review.
Growth slowing, weight gain, Cushingoid features, hypertension, muscle weakness or collapse after withdrawal raises hypothalamic–pituitary–adrenal suppression.
Investigation priorities
Confirm a steroid-responsive inflammatory diagnosis and exclude infection or tumour.
Management branches
A corticosteroid-responsive inflammatory eruption requires local treatment.
- Confirm diagnosis and activity, map body sites and check age, pregnancy, infection, barrier damage, previous response and every current topical product.
- Choose the lowest potency likely to control that severity at that site and select ointment for dry thick skin, cream for moist or cosmetically important areas, or lotion or solution for hair-bearing skin.
- Write one measurable course with site, fingertip units or grams, frequency, duration and stop or step-down instruction and demonstrate application.