Treating Eczema Symptoms With Topical Steroids
Topical steroids mimic natural cortisol to suppress the immune response, temporarily reducing itchiness and irritation.
Topical steroids can help manage acute flare symptoms but are not a cure for eczema and come with significant risks.
Introduction
Eczema is a chronic skin condition characterized by periodic acute flares, marked by red, itchy, and inflamed skin. The severity and duration of an acute eczema flare are influenced by three main factors:
Immune system sensitivity
Trigger intensity
Skin barrier strength
Among the multitude of treatment options, topical steroids can be used in the management of the symptoms such as itching, redness, and irritation, related to an acute flare. Topical steroids do not eliminate triggers, and can sometimes weaken the skin barrier further and therefore are effective only during acute flares for the temporary management of symptoms.(FUK 2014)
Here we provide a comprehensive understanding of topical steroids for eczema treatment, explaining their mechanism of action, types, usage, benefits, and potential risks, such as Topical Steroid Addiction and Withdrawal. With a deeper understanding of topical steroids we hope to empower you to make informed decisions about your skin health journey.
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What Are Topical Steroids?
Topical steroids, also known as corticosteroids or glucocorticosteroids, are medications that are applied directly to the skin to reduce the symptoms of itchiness and irritation related to inflammation during an acute flare.(HAJ 2015)(CAS 2006)
How Topical Steroids Work
The skin is tightly tied to the immune system. It signals the body when a trigger is present through molecules like histamine, which will induce an immune reaction. It also signals when the invader is no longer present by expressing cortisol. Cortisol lowers inflammation, essentially telling the immune system that it can take a break.
Topical steroids work by mimicking cortisol to suppress the immune response and therefore the downstream symptoms associated with an immune response such as itchiness, redness, and irritation.
Benefits for Eczema
Topical steroids offer a number of benefits for individuals dealing with eczema. By providing localized treatment, they reduce the systemic risks associated with immune suppression, providing targeted symptom relief and reducing inflammation. This is particularly beneficial for individuals whose eczema is characterized by an overactive immune response to a trigger on the skin.
However, it is important to understand that while topical steroids can help manage symptoms during an acute flare, they are potentially disturbing the natural inflammatory process, and they are not a long-term cure for eczema. Their primary role is to control inflammation and provide symptomatic relief.
A weakened skin barrier, or an excess of triggers in the environment, are critical concerns that need to be addressed in tandem to any symptom relief.
For long-term management of eczema, topical steroids should be used as part of a comprehensive treatment plan that may include other medications, lifestyle modifications, and strategies to avoid triggers.
Using Topical Steroids for Eczema Symptom Relief
Topical steroids can play a role in managing symptoms of eczema such as itching and redness. When used judiciously and as needed, they can provide a welcome break from the discomfort of a flare-up.
However, while these steroids help manage symptoms, it is important to concurrently consider your skin's barrier function and possible triggers. These factors must be addressed alongside any steroid usage to achieve effective resolution of a flare and long-term control of eczema.
Targeting Overactive Immune Responses with Topical Steroids
In some individuals with eczema, an overactive immune system can exacerbate the condition.
A strong immune reaction in a flare can further weaken the skin barrier and allow additional triggers through, thus sustaining a flare. In those cases, steroids can allow a temporary reduction of immune activity and a window of time for the skin to repair.
And for individuals with chronic eczema, topical steroids can effectively disrupt the itch-scratch cycle, also helping the skin barrier repair and the flare to resolve.
However, inflammation is not itself a marker of an overactive immune system; it can also be a natural response to a weakened skin barrier or strong environmental triggers. Monitor your symptoms using our tracking tools to identify potential triggers and prioritize maintaining a robust skin barrier. This approach can lower the amount of topical steroids required and manage eczema in a more comprehensive and health-conscious manner.
Moreover, topical steroids can be used in combination with other treatments, such as TC inhibitors, JAK inhibitors, or monoclonal antibodies. For instance, when used alongside Dupilumab, an effective monoclonal antibody therapy, it was observed to yield high overall effectiveness.(SED 2022) This combined approach not only lowers the overall dosage of steroids required but also provides a more targeted method to manage "overactive" immune responses.
Precautions, Risks & Side Effects of Topical Steroids for Eczema
While topical steroids offer benefits in managing eczema, they also carry significant potential risks and side effects.
While these drugs are sold over-the-counter, do not be fooled: they artificially lower your immune response and that should not be undertaken lightly.
Risks and side effects may include:
Topical Steroid Addiction and Withdrawal - Topical steroids are replacing the natural cortisol release from the skin and body. This can cause a lowered natural release of cortisol, which can develop into a dependency in some people. Please see our Topical Steroid Withdrawal page for more information. Each individual will have different sensitivities to these effects - some research indicates up to 12% of people will have a high sensitivity to topical steroids.
Other Systemic Side Effects - In rare cases, topical steroids can be absorbed into the bloodstream and cause systemic side effects such as weight gain, rounding of the face, thinning of bones, clouding of the eye lens, increased blood sugar levels or blood in the urine, and high blood pressure.
Increased Risk of Infection - Topical steroids can suppress the immune response in the skin, making it more susceptible to infections.
Thinning of the Skin - Topical steroids can lead to skin thinning or atrophy.
Allergic Reactions and Skin Irritations - In some cases, the skin may react negatively to the steroid or other components of the medication, causing itching, burning, or irritation.
Stretch Marks and Changes in Skin Appearance - Long-term use of topical steroids may lead to stretch marks, changes in skin color, and altered hair growth patterns.
To reduce chances of side effects, be mindful of how much topical steroids you use and when. See the tracking page for tools to do this effectively.
Talking to Doctors About the Risks of Topical Steroids
The above risks and potential side effects may be scary. However, many people tolerate topical steroids well when they are carefully used as directed.
Doctors are trained on and use manuals which tell them the order in which treatments should be deployed. These manuals are developed over many years of research and study, and remember the doctor motto is “do no harm”. So they will largely follow the manual on the order of treatments. If it is your first time talking to a primary care physician or a dermatologist about your symptom concerns, they are likely to offer topical steroids as the place to start.
If you are uncomfortable with that, your best bet is to share specific reasons why you personally cannot use steroids. Saying that you are uncomfortable with the risks, or read about TSW online, may not move them as they also have that information, and other treatments also come with serious costs or risks.
There are several reasons you could offer to a physician to help them work their way down the treatment list and consider other treatments. Some reasons could include:
- Intolerance or Allergy: Some patients may be allergic to the ingredients in the topical corticosteroid preparations, or they might develop contact dermatitis due to prolonged usage.
- Lack of Efficacy: Despite correct and regular application, the eczema flare may not be responding to topical steroids. Please see our tracking page on how to track and communicate your past experiences with treatments and symptoms.
- Risk of Side Effects: The prolonged use of potent topical steroids, particularly on sensitive areas like the face, folds of the skin, and genital area, can lead to skin thinning, stretch marks, rosacea or perioral dermatitis.
- Patient Concerns about Steroid Overuse: Some patients may have a strong worry about the side effects of prolonged steroid usage. Talking about topical steroid use in terms of this fear of long term use, may help you communicate your concerns, without directly challenging steroids. This fear can affect adherence to the treatment plan, making it less effective.
- Infants or Young Children: In children, particularly infants, the risk of systemic absorption is higher due to a greater skin surface area to weight ratio. Other treatments might be considered to reduce potential side effects.
- Pre-existing Medical Conditions: Certain conditions like rosacea, perioral dermatitis, or recent vaccination sites may be exacerbated by steroid usage.
- Pregnancy and Nursing: While most topical steroids are generally considered safe in pregnancy, there might be a preference to use other treatments as a precautionary measure.
If any of these conditions or factors are present, the physician might consider other options such as topical calcineurin inhibitors, emollients, or other systemic treatments.
You could also talk to the doctor about a regular follow-up schedule and actually schedule multiple appointments with the physician as evidence of your commitment to treatment. One reason a doctor may insist on steroids is that the manual says they are the first line treatment and regarded as safe. From their perspective if the patient goes home and they never see the patient again, topical steroids are the safest option.
This is especially true in the emergency room or urgent care departments - they are concerned that they cannot follow up. If you demonstrate a willingness to meet regularly to talk about side effects and treatment progression, they may be willing to move to other treatments knowing they can follow your progress.
Always remember, it is important to have an open and honest discussion with your healthcare provider about your symptoms, concerns, and any potential side effects you might be worried about.
Our page on talking to doctors goes into detail on how to track your treatment so you can show them your personal reaction and work together to find the right treatment plan.
Types of Topical Steroids for Eczema
Topical steroids for eczema come in a range of strengths and formulations, each designed to address different levels of disease severity and affected body areas. They are typically categorized into four classes, from mild to very potent forming a ladder of escalation if lower potency steroids are not sufficient.
- Mild: These are often used for sensitive areas of skin, like the face or areas where the skin folds. Examples include hydrocortisone 1% cream, which can often be found over-the-counter.
- Moderate: These are stronger than mild steroids and are typically used for areas of skin that are thicker, like the palms or soles of the feet. Examples include triamcinolone acetonide.
- Potent: These are even stronger and are used for brief periods on more stubborn patches of eczema. Examples include mometasone furoate and betamethasone valerate.
- Very potent: These are used sparingly for severe, resistant eczema under close supervision. An example is clobetasol propionate.
The different formulations—ointments, creams, lotions, and gels—serve various purposes. Ointments are usually more potent because of their occlusive nature, making them suitable for very dry, lichenified areas.(NHS)
Creams are less occlusive and may be more suitable for acute or weepy eczema. Lotions and gels are best for hairy areas or when minimal residue is desired, like on the scalp or face.
The strength and formulation of topical steroid to use depends on several factors, including the severity of eczema, the age of the person, the body area to be treated, and the presence of any other skin conditions.
It's crucial to consult with a healthcare provider to determine the appropriate type of topical steroid for your situation.
Over-the-Counter Options
Over-the-counter (OTC) topical steroids are available without a prescription and can provide a convenient and cost-effective way to manage mild to moderate eczema symptoms. The most common OTC topical steroid is hydrocortisone, which typically comes in a 1% concentration.
There are several benefits of OTC steroid creams for eczema. Firstly, they provide a degree of convenience, as they can be purchased from local drugstores without needing a doctor's prescription. Secondly, they are usually less expensive than prescription options, making them more accessible to a larger number of people. Lastly, OTC topical steroids are often sufficient for treating mild eczema symptoms, providing relief without the need for stronger, prescription-strength options.
Despite these advantages, it is important to note that even OTC topical steroids come with significant risks and potential side-effects. They should be used sparingly, not for prolonged periods, and never on sensitive areas like the face or groin unless specifically advised by a healthcare professional.
It is always a good idea to consult with a healthcare provider to determine the most suitable treatment for your specific condition and needs.
Prescription Topical Steroids for Eczema
Prescription topical steroids come in various strengths and formulations, and they tend to be more potent than over-the-counter versions.
Prescription topical steroids may be recommended when:
- Eczema is widespread or affects large areas of the body.
- There are unresolving, severe symptoms that significantly impact daily life, including persistent itching, discomfort, or disruption of sleep.
- Over-the-counter options have not provided sufficient relief or control of symptoms.
Some commonly prescribed topical steroids for severe eczema include betamethasone dipropionate, mometasone furoate, and clobetasol propionate, among others. These steroids are potent to very potent.
However, due to their strength, these medications should be used under the guidance of a healthcare provider to avoid potential side effects. A specific regimen will be provided, which will specify how much to apply, how often to use it, and how long the treatment course should last.
This regimen should be followed carefully to ensure optimal treatment results and minimize the risk of side effects.
Applying Topical Steroids
Always follow your healthcare provider's specific instructions as the application protocol can vary based on the severity of your condition and the area affected.
Here are some general rules to consider along with your healthcare provider’s instructions:
- Topical steroids should be applied to the affected areas only, in thin, measured quantities using clean hands. It is important to avoid applying the medication on unaffected skin. If you are applying the medication with your hands and your hands do not need treatment, make sure to wash them thoroughly afterward.
- The frequency and duration of use of topical steroids should be closely monitored due to the potential for adverse effects. Tracking your symptoms against your use is a powerful tool for discussion with your healthcare provider. For guidance on tracking your usage and symptoms, refer to our [tracking] page.
- Each topical steroid product typically comes with an information sheet that provides specifics about usage and dosage for different parts of the body. Refer to these instructions to determine the correct amount to use for each application.
- Remember that certain areas of the body, such as the face and neck, have thinner and more sensitive skin. Topical steroids should be used sparingly or avoided entirely in these regions. For these sensitive areas, alternative treatments like topical calcineurin inhibitors may be more suitable. Always discuss any concerns or side effects with your healthcare provider to ensure safe and effective treatment.
- Topical steroids come in different formulations—ointments, creams, lotions, and gels—each serving a specific purpose. Ointments, due to their occlusive nature, are typically more potent and beneficial for very dry, lichenified areas of skin. Creams are less occlusive, making them more suitable for acute or 'weepy' eczema. Lotions and gels, on the other hand, are ideal for hairy areas or when minimal residue is desired, such as on the scalp or face.
What About Other Treatments?
While topical steroids can be effective for treating eczema symptoms and allowing a window for the skin barrier to heal, it is crucial to remember that they do not cure eczema or address the underlying causes. They are intended to manage symptoms and improve quality of life as part of a comprehensive treatment plan.
Long-term management should include the identification and elimination of triggers and a strengthening of the skin barrier.
An essential aspect of eczema management is working closely with your healthcare provider to develop a tailored treatment plan that considers your specific needs and circumstances. This collaborative approach ensures that the most appropriate treatments are selected and any potential risks or side effects are monitored closely.
Remember that each individual's experience with eczema and response to treatments will differ. It may take some trial and error to determine which combination of therapies works best for you. Maintaining open communication with your healthcare provider is crucial for adjusting your treatment plan as needed.
About the Author(s)
Dr. Nicole Scott, PhD, MPH
Dr. Scott has published 29 peer-reviewed papers regarding human biology and the microbiome. Her work has been cited over 4300 times by other scientists.
She has battled eczema for most of her life and is the Founder of Rulo Skin.