CHILD HEALTH DERMATOLOGY

Topical corticosteroids for childhood

eczema: clearing up the confusion
Topical corticosteroids are one of the key medicines used in the management of childhood eczema. However,
adherence is typically poor, often due to “corticosteroid phobia”.

KEY PR AC TICE POINTS

This is a revision of a previously published article.
Use the lowest potency topical corticosteroid needed to
control the patient’s symptoms What’s new for this update:
Changes to topical calcineurin inhibitor funding
Be clear when prescribing where each product should, and
should not, be used; avoid the term “use sparingly” status:
Check that patients and caregivers can identify a flare and – Topical pimecrolimus is now funded with
are able to respond with appropriate treatment Special Authority approval for treatment
For patients with persistent eczema, short treatment “bursts”, of eczema affecting the eyelid if topical
e.g. three to five days, with higher potency corticosteroids corticosteroids cannot be used
may be preferable to longer courses of treatment with less – Tacrolimus ointment is now an approved
potent corticosteroids; topical corticosteroids should be
medicine in New Zealand for people aged
stepped down, e.g. from potent or moderate potency to
≥ 16 years and will be funded with Special
mild potency, as the patient’s symptoms resolve
Authority approval from October, 2021,
Include descriptions of potency in the prescription so that it
for eczema affecting the face if topical
is printed on the medicine label to avoid confusion
corticosteroids cannot be used
Table of topical corticosteroids has been updated
For general information on the treatment of childhood
to reflect currently funded brands
eczema, see the companion article: “Childhood eczema:
improving adherence to treatment basics”

www.bpac.org.nz July 2021 1

Navigating common questions and concerns Provide clear information when prescribing
Topical corticosteroids are one of the key medicines used in and dispensing topical corticosteroids
the management of childhood eczema. However, adherence
Avoid “use sparingly”: encourage appropriate use
is typically poor, often due to “corticosteroid phobia”. Common
themes contribute to the reluctance of caregivers to use Advising patients to “use topical corticosteroids sparingly”
topical corticosteroids (Table 1). Addressing these concerns creates confusion; patients and caregivers are prescribed a
may improve treatment adherence and patient outcomes.2 medicine but simultaneously warned against using it.5

Table 1: Caregiver misconceptions and concerns associated with the use of topical corticosteroids for eczema in children and
evidence-based responses.3–6

Misconception or concern What does the evidence say?

Topical corticosteroids Topical corticosteroids can and should be used for all severities of eczema, including mild
should only be used for symptoms.
severe symptoms
Products have a range of potencies to treat patients with differing symptom severity.
Treatment should be with the mildest topical corticosteroid which is able to resolve the
inflammation within a short period of time so that the patient is able to have days without
using topical corticosteroids. Different potencies are required for different parts of the body
depending on the thickness of the stratum corneum.

Regular use of topical Topical corticosteroids are unlikely to cause skin thinning or other long-term harm to
corticosteroids causes children if used appropriately.
adverse effects such as skin
Skin thinning is one of the most frequently cited concerns reported by patients and
thinning
caregivers, however, is very unlikely to occur if patients and caregivers use topical
corticosteroids appropriately.2, 7, 8 This consensus is based on research and clinical experience
from Australia and New Zealand, including evaluations of children treated with potent
corticosteroids.7 Skin thinning is more likely to occur in adults, or in areas with a thinner
stratum corneum, such as the face and groin.2

The percentage of a topical The percentage value of different formulations of topical corticosteroids does not indicate
corticosteroid is its strength their potency, e.g. hydrocortisone 1% is a weaker formulation than hydrocortisone butyrate
0.1%.

Corticosteroids are confused Clarify the meaning of the word “steroid”.

with anabolic steroids
Inform patients and caregivers that the label “steroids” is a classification used for a wide
group of hormones and medicines with different functions, including corticosteroids and
anabolic steroids.

Topical corticosteroids should The consensus of paediatric dermatologists in Australia and New Zealand is that topical
not be applied to broken skin corticosteroids can be applied to areas of eczema with broken skin.7
This recommendation possibly arose as topical corticosteroid absorption will be greater
through broken skin. However, this can prevent patients having topical corticosteroids
applied to areas of active eczema particularly when severely inflamed or excoriated. All skin
with an active eczema flare will have reduced barrier function, and the best way to address
this is through appropriate use of topical corticosteroids.9

Topical corticosteroids are Corticosteroids mimic the effects of hormones produced by the adrenal glands, despite being
not “natural” “man-made”.

* For further information on symptom severity and recommended treatment escalation, see: https://bpac.org.nz/BPJ/2015/April/eczema.aspx

2 July 2021 www.bpac.org.nz

This advice may result in corticosteroids only being used when For patients with persistent eczema, short “bursts” with
symptoms are severe, leading to inadequate use and poor higher potency corticosteroids, e.g. betamethasone
symptom control. Caregivers should instead be encouraged valerate 0.1% twice daily for three to five days, may
to “use corticosteroids appropriately”, which will maximise the be preferable to longer courses of treatment with less
benefits of use and minimise adverse effects. potent corticosteroids. Betamethasone valerate 0.1%
Patients/caregivers should know:9 twice daily for three days is as effective as hydrocortisone
1. Which corticosteroid to apply, i.e. using the right 1% twice daily for seven days. Patients can be treated
potency and formulation with a higher potency corticosteroid initially to gain
control of symptoms and then stepped down to a less
2. Where on the body to apply it
potent formulation, e.g. hydrocortisone 1%.
3. When to apply it, i.e. when to start treatment and how
– This results in quicker resolution of symptoms and
long to use it for
shorter treatment duration
4. How much to apply
– If patients are switched to higher potency
corticosteroids ensure they understand that the
Arrange to review the patient within two to four weeks of
treatment period is shorter
prescribing topical corticosteroids. This gives an opportunity to
assess their response to treatment and reinforce education as If a lower potency of corticosteroid is needed, prescribe a
well as allowing the patient and caregiver to focus on treating weaker corticosteroid rather than diluting a more potent
the eczema rather than watching for adverse effects. formulation
– Diluting topical corticosteroids with emollients does
Which corticosteroid and formulation to not result in a less potent medicine. Potency is related
apply to the affinity of the particular corticosteroid molecule
to the receptor.
There are a range of fully funded or partly funded topical
corticosteroids available to prescribe for children with eczema Include corticosteroid potency on medicine labels
(Table 2).10, 11 In addition, some topical corticosteroids are – Patients and caregivers may believe that the
available over-the-counter without a prescription, including:10 percentage of a topical corticosteroid determines it’s
Pharmacy only medicine – hydrocortisone 0.5% strength, e.g. that hydrocortisone 1% is stronger than
Pharmacist only medicines – hydrocortisone 1% hydrocortisone butyrate 0.1%, without realising that
and clobetasone butyrate 0.05%, which are also different corticosteroids have differing potencies.4
available fully funded or partly funded on prescription, Labelling a topical corticosteroid as mild, moderate,
respectively potent or very potent (Table 2) or similar terms that
will be clear to patients, e.g. low, medium, strong, very
Consider the consistency of the product required:1, 12 strong, on medicine labels, avoids confusion and the
Creams, lotions or gels are useful for large areas of skin risk of inappropriate use.
Lotions, solutions or gels are useful for the scalp or other
Very potent topical corticosteroids, i.e. betamethasone
areas with hair
dipropionate 0.05% (in propylene glycol base) and
Ointments are useful for very dry skin and skin with thick
clobetasol propionate 0.05%, should not be initiated in
scale
children without prior discussion with a dermatologist
Key points when selecting the potency of topical
corticosteroids include:2, 5, 7–9, 13 Provide a written plan for the patient and caregiver to take
Use the lowest potency corticosteroid needed to control home. This can help to remind them which topical corticosteroid
symptoms, e.g. hydrocortisone 1% daily or twice daily for to apply where. For an example, see: www.starship.org.nz/
mild eczema. However, be prepared to increase potency, for-health-professionals/new-zealand-child-and-youth-
particularly for eczema on the trunk and limbs, if a mild clinical-networks/child-and-youth-eczema-clinical-network/
topical corticosteroid is not working. family-information-and-handouts/

www.bpac.org.nz July 2021 3

Table 2: Prescription only topical corticosteroid potency and currently funded formulations, sizes and brands, as of July, 2021.10, 11
Check the NZF or Pharmaceutical Schedule for up to date information on funding status.

Potency Active ingredient Formulations available

Lotions or liquids Cream Ointment

Useful for large areas of Useful for large areas of Useful for skin
skin, the scalp or areas skin with thick scale
with hair

Prescription only medicines

100 g, 500 g
Mild Hydrocortisone 1% Hydrocortisone PSM

Moderate Clobetasone butyrate 0.05% 30 g

(2 – 25 × as potent as Eumovate
hydrocortisone)

100 g 100 g
Triamcinolone acetonide 0.02% Aristocort Aristocort

Potent‡ Betamethasone dipropionate 15 g, 50 g 15 g, 50 g

(100 – 150 × as potent 0.05%* † Diprosone Diprosone
as hydrocortisone)

Lotion 50 mL
50 g 50 g
Betnovate
Betamethasone valerate 0.1% †
Application 100 mL
Beta Beta
Beta Scalp Application

50 g
Diflucortolone valerate 0.1% Nerisone

Scalp Lotion 100 mL

Locoid 100 g 100 g
Hydrocortisone butyrate 0.1% Topical emulsion 100 mL Locoid Lipocream Locoid
Locoid Crelo

Methylprednisolone aceponate 15 g 15 g
0.1% Advantan Advantan

Lotion 30 mL 15 g, 50 g 15 g, 50 g
Mometasone furoate 0.1% Elocon Elocon Alcohol free Elocon

Very potent‡ Betamethasone dipropionate 30 g

(up to 600 × as potent
0.05%*† Diprosone OV
as hydrocortisone)

Application 30 mL 30 g 30 g
Clobetasol propionate 0.05%† Dermol Dermol Dermol

Fully funded; Partly funded;

* Betamethasone dipropionate is available as a potent formulation (Diprosone) or modified formulation with increased potency (Diprosone OV; very
potent), both containing 0.05% active ingredient
† Not approved for use in children aged under 12 months10
‡ Note that the face, flexural areas, genitals and the groin are more prone to irritation and skin atrophy than other sites; treatment of these areas is usually
limited to mild or moderate potency topical corticosteroids8, 13

4 July 2021 www.bpac.org.nz

Recommendations for topical corticosteroid Topical calcineurin inhibitors are an alternative treatment
use if the use of topical corticosteroids is contraindicated or not
appropriate.13, 14 There are two topical calcineurin inhibitors
Where on the body should they be applied? approved for use in New Zealand:11, 14
Topical corticosteroids should only be applied on actively Pimecrolimus is funded with Special Authority approval
affected areas of eczema in an appropriate amount (see: “How for treatment of eczema affecting the eye lid if topical
much should be used?”).10 When prescribing, be clear where corticosteroids cannot be used
each product should be used, e.g. lower potency topical
Tacrolimus ointment is approved for use in people aged
corticosteroids for the face, and specify the treatment duration
≥ 16 years and will be funded from 1 October, 2021, with
and any areas of the body where use of the corticosteroid
Special Authority approval for eczema affecting the face
would be inappropriate (Figure 1). For example:7, 9
if topical corticosteroids cannot be used
Methylprednisolone aceponate 0.1% cream

Potent (strong) corticosteroid – apply once daily to eczema Patients may self-fund for other indications. Calcineurin
on the limbs and trunk until the flare has cleared. Seek inhibitors are more likely to cause a burning sensation and
medical attention if symptoms persist after seven days. pruritis than topical corticosteroids.10, 15 A possible association
between topical calcineurin inhibitor use and increased risk of
Mitte 15 g and 2 repeats
lymphoma has been examined in a recent systematic review
Caution is required when applying topical corticosteroids and meta-analysis.16 Analyses did find an association, however,
to the face, periorbital or perioral regions and flexural or the overall risk is very small.16
groin areas
The face, flexural and groin areas are more susceptible to
When should they be applied?
adverse effects such as striae or skin atrophy and systemic
absorption is increased in these areas compared to other Check that patients and caregivers understand when to initiate
sites.2 For children with eczema affecting the face, use mild treatment with topical corticosteroids and when treatment
potency or short courses of moderate potency topical should be stepped down or withdrawn:2, 8, 13
corticosteroids.13 In flexural or groin areas moderate or potent Emollient use should continue during flares
topical corticosteroids should be used only for short periods,
Topical corticosteroids should only be applied to areas of
e.g. up to seven days.13
active eczema, unless during “weekend treatment” (see:
“How long should they be applied for?”)
In periorbital regions potent or very potent topical
corticosteroids should not be used. Initially, once daily application of topical corticosteroids
is often sufficient; no more than twice daily. As
In perioral regions the use of even mild topical formulations symptoms improve treatment can be stepped down
has been associated with the development of periorificial by either applying a lower potency corticosteroid with
dermatitis or “steroid rosacea”.7 Ongoing use of topical the same frequency, or the same potency corticosteroid
corticosteroids may aggravate these conditions.7 applied less frequently.

Trunk, legs or arms: Facial or flexural eczema:

Infants aged < 1 year: First-line:
Low potency corticosteroids Low potency corticosteroids
Pre-school aged children: Second-line or severe eczema:
Generally require a moderate or Moderate potency topical
potent topical corticosteroid corticosteroids for five to seven days
School-aged children:
Often require a potent topical
corticosteroid

Figure 1: “Rules of thumb” to guide topical corticosteroid use, from www.bpac.org.nz/BPJ/2016/February/eczema.aspx

www.bpac.org.nz July 2021 5

How long should they be applied for? seven days in total during a month, this would equate to:

4 × 0.5 g × once daily × seven days = approximately 14 g

Topical steroids should generally be effective in clearing
inflammation so that long-term treatment is primarily with Usage may vary depending on the extent of flares, how quickly
emollients. they resolve, whether topical corticosteroid use is tapered or
Flares should typically resolve within seven to 14 days of stepped down, and whether patients are also using topical
treatment.8 If treatment is not effective, check adherence, corticosteroids during “weekend treatment”.
consider if the treatment should be changed or re-
consider the diagnosis.8
For patients in whom treatment is effective but they
have frequent flares, “weekend treatment”, also known
as maintenance therapy, should be considered. This
consists of applying topical corticosteroids for two days a
week during remission.13
– A study involving patients using “weekend treatment”
of betamethasone dipropionate (0.05%) showed
that 74% of participants maintained remission
for 12-weeks and developed no adverse effects
like skin atrophy or Cushing’s syndrome (see: “The
adverse effects of topical corticosteroids are mild Figure 2. Fingertip unit
and reversible”).1 Since this study, large-multicentre
studies have achieved similar results.1 The adverse effects of topical corticosteroids
are mild and reversible
How much should be used? Shortly after application of a topical corticosteroid some
Calculate how much topical corticosteroid to prescribe and if patients may experience local irritation or a change in skin
possible, provide an indication of when a repeat prescription colour caused by corticosteroid-induced vasoconstriction.2
is likely to be required. Caregivers can use fingertip units (FTU) Hypopigmentation typically clears when the topical
to guide the amount of topical corticosteroid to apply (Table corticosteroid is stopped.7 Changes in pigmentation usually
3 and Figure 2). A fingertip unit is the amount of product that occur due to the eczema itself or another dermatological
covers the tip of an adult’s index finger to the distal skin crease condition, e.g. pityriasis alba.7, 17
from a standard 5 mm tube.10 This is a sufficient quantity for an There is little evidence as to what percentage of a
area of skin equal to the palms of two adult hands. One FTU is topical corticosteroid dose is absorbed systemically. Studies
approximately 0.5 g.10 investigating systemic effects do not measure how much
For example, a child aged five years with eczema mainly of the corticosteroid is in the blood, but instead focus on
affecting one arm and hand will require approximately four measuring cortisol as a marker of hypothalamic-pituitary-
FTU of topical corticosteroid per application (Table 3). If this is adrenal (HPA) axis suppression. After a few weeks’ treatment
applied once daily during flares, and flares last approximately with potent or very potent topical corticosteroids temporary

Table 3: Approximate number of adult fingertip units (FTU) of corticosteroid needed per application for children with eczema.1, 10 *

3 – 6 months 1 – 2 years 3 – 5 years 6 – 10 years 11 – 18 years

One entire arm and hand 1 1.5 2 2.5 4

One entire leg and foot 1.5 2 3 4.5 8

Torso (front) 1 2 3 3.5 7

Back and buttocks 1.5 3 3.5 5 7

Face and neck 1 1.5 1.5 2 2.5

* Note that these values are a guide and will be influenced by the size of the child

6 July 2021 www.bpac.org.nz

HPA axis suppression does occur. However, this resolves upon
Acknowledgement: This article is a revision of an original
cessation of the topical corticosteroid, without the need for
article published by bpacnz in 2016. The original article was
dose tapering.7 HPA axis suppression is more likely when
reviewed by Dr Diana Purvis, Dermatologist, Auckland DHB.
topical corticosteroids are applied under occlusion, e.g. with
Article supported by PHARMAC
wet wraps as greater systemic absorption occurs.8, 13
N.B. Expert reviewers do not write the articles and are not responsible for
Inappropriate or prolonged use may cause more the final content. bpacnz retains editorial oversight of all content.
serious adverse effects
More serious adverse effects include clinically significant
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www.bpac.org.nz July 2021 7