One late night at a retail pharmacy, Jay Harold was asked by a male high school student if it was okay to take his mother’s Premarin tablets. He was trying to get bigger and stronger to get a college football scholarship and reasoned that taking hormones would help. He wasn’t aware that Premarin is used after menopause to reduce moderate to severe hot flashes. He was trying to obtain an anabolic steroid. This post will focus on topical steroids. “Topical Steroids: Uses and 5 Side Effects,” will provide useful information about this important class of drugs.
You may have heard of anabolic steroids1, which can have harmful effects. Anabolic steroids are man-made substances related to male sex hormones. Doctors use anabolic steroids to treat some hormone problems in men, delayed puberty, and muscle loss from some diseases. But there’s another type of steroid – sometimes called a corticosteroid2 – that treats a variety of problems. These steroids are similar to hormones that your adrenal glands make to fight stress associated with illnesses and injuries. They reduce inflammation and affect the immune system.
You may need to take corticosteroids to treat:
- Arthritis
- Asthma
- Autoimmune diseases such as lupus and multiple sclerosis
- Skin conditions such as eczema and rashes
- Some kinds of cancer
Steroids are potent medicines, and they can have side effects, including weakened bones and cataracts. Because of this, you usually take them for as short a time as possible.
What’s the Right Amount of Topical Steroid to Use?
1 fingertip unit (1 FTU)
Depending on the area of skin, the following amounts (in FTU) are recommended:
5 Side Effects of Topical Steroids
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 (1). 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 afterward.
Other possible side effects include small changes in pigmentation(2) (white spots), and temporary blisters(3). Another possible side effect is known as telangiectasia(4). 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(5) because steroids inhibit the immune function of the skin.
How to avoid the Side Effects
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 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 during 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.
Preventing Flare-ups
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 to see whether you still need it.
Pimecrolimus and Tacrolimus
Two other medications have been approved in Germany (and the U.S.) for the treatment of eczema: Pimecrolimus3 (trade name: Elidel) and tacrolimus4 (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.
Other topical steroids used for eczema include PDE4 inhibitors like Eucrisa5 (crisaborole).
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:
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If steroids haven’t led to a big enough improvement.
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for the treatment of particularly sensitive areas such as the genitals or face, and especially the eyelids.
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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.
There are 7 different classes of topical steroids6
Topical steroids are classified by strength, which ranges from “super potent” (Class 1), to “least potent” (Class 7). Many brand-name topical steroids also have generic versions. If your doctor feels it’s important to treat your eczema with a particular steroid formulation, they may not prescribe the generic version. If your doctor wants you to try a brand name steroid, check drug manufacturer’s website for any kind of co-pay assistance program. The National Eczema Association’s website has a resource page
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