Topical corticosteroids have revolutionized the treatment of inflammatory skin diseases. They are double edged swords, the use of which should be carefully titred according to their potency.
Topical corticosteroids are grouped according to their potency or strength. Topical steroids vary from very strong, super potent (Class 1), to very weak or least potent (Class 7). The super potent steroids are very effective in controlling severe inflammation of the skin, but have very high incidence of side effects. As the potency decreases, so does the effectiveness and side effects.
Classes of Topical Corticosteroids
Following are the classes of topical steroids:
- Class 1: Superpotent Corticosteroids: These are used in chronic inflammation of the skin where the skin is thickened (lichenified), pigmented and/or thick scaled. A few examples of superpotent steroids are clobetasole propionate and halobetasole propionate. Indications of superpotent steroids include neurodermatitis, thick scaled psoriasis etc.
- Class 2: Potent Corticosteroids: These are used in chronic inflammation where the thickness, pigmentation or scales are less than the above lesions. Examples of potent steroids are betamethasone dipropionate, halcinonide, fluocinonide. Indications of potent steroids are: lichen planus, neurodermatitis, moderately severe psoriasis vulgaris, chronic eczema etc.
- Class 3: Upper Mid-Strength Corticosteroids: These are used in sub acute inflammation of the skin. Examples of upper mid-strength steroids are betamethasone valerate and fluticasone propionate. Uses in sub acute dermatitis, infective eczema, psoriasis, severe seborrheic dermatitis etc.
- Class 4: Mid-Strength Corticosteroids: These are used in sub acute and acute inflammation of the skin. Examples of mid-strength steroids are mometasone furoate, fluocinolone acetonide 0.025%, and triamcinolone acetonide. Uses in sub acute dermatitis, infective eczema, moderately severe seborrheic dermatitis, psoriasis, atopic dermatitis, alopecia areata etc.
- Class 5: Lower Mid-Strength Corticosteroids: These are used in sub acute and acute inflammation of the skin. Examples of lower mid-strength corticosteroids are hydrocortisone butyrate, fluticasone propionate. Uses in infective eczema, seborrheic dermatitis, mild psoriasis etc.
- Class 6: Mild Corticosteroids: These are used in acute and sub acute inflammation of the skin. Examples of mild corticosteroids are desonide, fluocinolone 0.01%, clobetasone. Uses in sub acute and acute dermatitis, mild seborrheic dermatitis etc.
- Class 7: Least Potent Corticosteroids: These are used in mild acute and sub acute inflammation of the skin. Steroid responsive skin diseases of the face, flexures, and napkin area have to be treated with this class of topical steroids to avoid damage to the skin. Example of least potent steroids is hydrocortisone 1%.
Topical corticosteroids come in several forms, including creams, lotions and ointments. Creams and solutions are a class below in potency than ointments. Ointments are greasy and preferred in chronic dermatitis and scaly diseases like psoriasis. Creams can be used in acute and subacute skin inflammation. Gels and lotions are preferred in hairy areas and scalp.
Topical corticosteroids in psoriasis and other skin diseases form the mainstay of treatment in such inflammatory dermatoses. A knowledge of the groups of topical corticosteroids according to their potency is indeed essential in learning how to avoid side effects of topical steroids in psoriasis and other steroid responsive skin diseases.
Reference
- Warner M, Camisa C. Topical Corticosteroids. Comprehensive Dermatologic Drug Therapy, WB Saunders. 2001; Ch. 27. 548-577.
- Topical Therapy, in Rook’s Textbook of Dermatology, 7th Edition, 2004
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