Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
Selecting potency and vehicle for topical corticosteroids
Essential points for quick revision.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Systemic toxicity or dangerous infection
Hypotension, vomiting, profound weakness, hypoglycaemia or collapse after abrupt withdrawal of prolonged large-area potent corticosteroid exposure suggests adrenal insufficiency; fever, severe pain, grouped vesicles, purpura, necrosis or rapidly spreading warmth suggests infection masked by treatment.
Action: Stop inappropriate local application but treat suspected adrenal crisis, eczema herpeticum, cellulitis or sepsis immediately through the acute pathway, document the exact product and weekly quantity, and obtain urgent endocrinology, paediatric or dermatology advice rather than improvising a rapid taper.
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.
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.
Systemic absorption signal
Growth slowing, weight gain, Cushingoid features, hypertension, muscle weakness or collapse after withdrawal raises hypothalamic–pituitary–adrenal suppression.
Investigation priorities
01
Morphology and full-site examinationFirst step
Confirm a steroid-responsive inflammatory diagnosis and exclude infection or tumour.
Management branches
First-line selectionMatch disease, site and vehicle
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.
Key medicines
Hydrocortisone 1% mild corticosteroidApply a thin measured layer once or twice daily to the prescribed active site for the defined short course; use age- and condition-specific limits and stop or step down when control is achieved.
Clobetasone butyrate 0.05% moderate corticosteroidApply thinly once or twice daily to a clearly mapped area for the condition-specific short course, measuring quantity by fingertip units and reviewing before repeat use.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.