Corticosteroids - topical (skin), nose, and eyes
Exam Tips
- In UK exams, always state: correct diagnosis first, then lowest effective potency, correct vehicle, shortest duration, and clear review date.
- Potency rule of thumb: mild for face/flexures/genitals; potent for thicker trunk/limb plaques; very potent only short-term and usually specialist-directed.
- Ointment is generally more occlusive (and effectively stronger) than the same steroid in cream form; pick by lesion morphology and site.
- Nasal sprays are usually safer than drops for long-term use; demonstrate septum-sparing technique to reduce epistaxis.
- Never prescribe steroid eye drops for an undifferentiated red eye in primary care OSCE scenarios without ophthalmology input.
- See Figure from page X (topical steroid potency ladder and site-based prescribing map).
Definition
Topical (cutaneous), intranasal, and ophthalmic corticosteroids are locally delivered glucocorticoid preparations used to control inflammation in steroid-responsive skin, nasal, and eye disorders. They reduce symptoms such as itch, congestion, and ocular inflammation while limiting systemic exposure compared with oral steroids, but inappropriate potency, duration, or site of use can still cause important local and systemic adverse effects.
Pathophysiology
These agents bind intracellular glucocorticoid receptors and alter gene transcription, reducing phospholipase A2 activity and downstream prostaglandin/leukotriene production, while also suppressing T-cell mediated inflammation. Clinically relevant effects are anti-inflammatory, immunosuppressive, anti-proliferative (reduced epidermal turnover), and vasoconstrictive (greater with higher potency). Absorption and toxicity vary by formulation and site: ointments are more occlusive than creams, thin skin (face/genitals/eyelids) absorbs more than palms/soles, and occlusion increases penetration; for intranasal therapy, drops can carry higher systemic risk than sprays if technique is poor. See Figure from page X (glucocorticoid receptor signaling and local tissue effects).
Risk Factors
- Atopic disease or chronic inflammatory dermatoses (eczema, psoriasis, dermatitis) requiring repeated courses
- Allergic rhinitis or chronic rhinosinusitis with nasal polyps
- Ocular inflammatory disease (for example anterior uveitis or post-operative inflammation) under specialist care
- High-potency steroid use on thin skin sites, large body surface area, prolonged duration, or under occlusion
- Extremes of age (infants/children and older adults) due to higher absorption and skin fragility
- Previous glaucoma/cataract or recurrent ocular herpes simplex infection
- Concomitant strong CYP3A4 inhibitors (for example ritonavir/cobicistat) increasing systemic steroid exposure, especially with fluticasone
Clinical Features
Symptoms
- Inflammatory skin disease: itch, soreness, dryness, lichenification, scaling, flare-related sleep disturbance
- Nasal disease: obstruction, rhinorrhoea, sneezing, itching, reduced smell, postnasal drip
- Ocular inflammation: redness, pain/photophobia, blurred vision, tearing
- Adverse effects to ask about: skin burning/stinging, epistaxis, nasal dryness, ocular irritation
Signs
- Skin: erythema, excoriation, plaques, lichenification, fissuring; site-specific distribution guides potency choice
- Nose: swollen pale/boggy turbinates (allergic pattern), polyps, mucosal inflammation
- Eyes: conjunctival injection, anterior chamber inflammation (specialist assessment), post-op inflammation
- Steroid toxicity signs: skin atrophy, striae, telangiectasia, purpura, periorificial dermatitis, steroid acne, raised intraocular pressure
Investigations
Management
Lifestyle Modifications
- Use the least potent preparation for the shortest effective duration; step down as control improves
- Teach correct application: fingertip-unit method for skin, head-forward spray technique for nose, strict drop hygiene for eyes
- Avoid irritants/triggers and continue adjunctive non-steroid care (for example regular emollients in eczema, allergen reduction in rhinitis)
- Review adherence, overuse, and steroid phobia at follow-up; document site, potency, and planned stop/review date
Pharmacological Treatment
Topical corticosteroids for skin (by potency/site)
- Hydrocortisone 1% cream/ointment: apply once or twice daily (mild potency, often face/flexures, short course)
- Clobetasone butyrate 0.05% cream/ointment: apply once or twice daily (moderate potency)
- Betamethasone valerate 0.1% cream/ointment/lotion: apply once or twice daily (potent, usually trunk/limbs short course)
- Clobetasol propionate 0.05% cream/ointment/scalp: apply once or twice daily, usually up to 1-2 weeks; do not exceed 50 g/week (very potent)
Choose vehicle by lesion type: ointment for dry/lichenified lesions; cream for moist/weeping lesions; lotion/gel/foam for hairy areas. Avoid potent/very potent steroids on face/genitals/skin folds unless specialist-directed. Contraindications/cautions: untreated bacterial, fungal, or viral skin infection (including herpes/varicella), rosacea, perioral dermatitis, acne vulgaris for many products, and broken skin if product-specific advice warns against use.
Intranasal corticosteroids
- Beclometasone dipropionate 50 micrograms/spray: 2 sprays each nostril twice daily initially, then reduce to maintenance
- Fluticasone propionate 50 micrograms/spray: 2 sprays each nostril once daily (200 micrograms/day), maintenance 1 spray each nostril once daily
- Mometasone furoate 50 micrograms/spray: 2 sprays each nostril once daily (200 micrograms/day), then lowest effective maintenance
- Budesonide nasal spray (dose varies by product): typically once daily or divided dosing per product labeling
Sprays are generally preferred to drops for safety and ease; aim nozzle away from nasal septum to reduce epistaxis. Common adverse effects: epistaxis, dryness, irritation. Use caution with strong CYP3A4 inhibitors (especially fluticasone) due to systemic steroid effects; monitor children for growth with long-term use.
Ophthalmic corticosteroids (specialist-led/diagnosis-confirmed use)
- Prednisolone acetate 1% eye drops: 1-2 drops 2-4 hourly initially in active inflammation, then taper
- Dexamethasone 0.1% eye drops: typically 1 drop 4-6 times daily, then taper to response
- Fluorometholone 0.1% eye drops: commonly 1 drop 2-4 times daily for milder inflammation
Do not start steroid eye drops in an undiagnosed red eye without ophthalmic assessment. Contraindications/cautions: epithelial herpes simplex keratitis, untreated purulent/fungal/mycobacterial eye infection, glaucoma risk, and prolonged unsupervised use. Monitor intraocular pressure and cataract risk when courses are extended; advise no contact lens wear during active inflammation unless specialist advises otherwise.
Combination preparations when indicated
- Topical steroid + antibacterial combinations (for example with fusidic acid or neomycin) for short, clearly infected inflammatory dermatoses
- Topical steroid + antifungal combinations (for example with miconazole or clotrimazole) for inflamed fungal dermatoses in selected short courses
- Intranasal steroid + antihistamine combinations (for example fluticasone with azelastine) in persistent allergic rhinitis
Use combinations only when the additional component is clinically indicated; avoid prolonged use to reduce antimicrobial resistance and steroid adverse effects.
Surgical / Interventional
- Endoscopic sinus surgery or polypectomy for refractory chronic rhinosinusitis with polyps despite optimal medical therapy
- Ophthalmic procedures according to underlying diagnosis (for example post-operative anti-inflammatory steroid regimens under specialist supervision)
Complications
- Cutaneous atrophy, striae, telangiectasia, purpura, delayed wound healing, steroid rosacea/perioral dermatitis, and tinea incognito
- HPA-axis suppression/Cushingoid features (uncommon, but risk rises with potent agents, large areas, occlusion, prolonged use, and CYP3A4 interactions)
- Intranasal adverse effects including recurrent epistaxis and, rarely, septal perforation
- Ophthalmic steroid complications: raised intraocular pressure, glaucoma progression, posterior subcapsular cataract, worsened undiagnosed infection
Prognosis
Most patients achieve good symptom control when potency, formulation, and duration are matched to site and diagnosis, with regular review and step-down. Prognosis worsens with misdiagnosis (especially occult infection), poor technique/adherence, and prolonged high-potency exposure without monitoring.