Dermatitis - contact

Prescribing Notes:

• There is a risk of severe and fatal burns with all paraffin based emollients regardless of the paraffin concentration. Data suggest there is also a risk for paraffin-free emollients. Patients who use these products should not smoke or go near naked flames. Emollients can transfer from the skin onto clothing, bedding, dressings, and other fabric. Once there, they can dry onto the fabric and build up over time. In the presence of a naked flame, fabric with emollient dried on is easily ignited. Although emollients are not flammable in themselves or when on the skin, when dried on to fabric they act as an accelerant, increasing the speed of ignition and intensity of the fire.
• Patient clothing and bedding should be changed regularly - preferably daily. Washing clothing or bedding at a high temperature may reduce the emollient build up but not totally remove it.
• Resources are available for health and social care professionals to support the safe use of emollients see MHRA guidance.
• A similar risk may apply for other products which are applied to the skin over large body areas, or in large volumes for repeated use for more than a few days.
• Content is available on the Dermatology pages of the Right Decision Service to provide an accessible resource for primary care practitioners to support the diagnosis and management of patients presenting with common skin conditions.
• The vehicle used in topical preparations influences skin hydration, has a mild anti-inflammatory effect and facilitates penetration of the active component.
• Creams are more cosmetically acceptable than ointments because they are less greasy and easier to apply. Gels may be used on the face and scalp while lotions have a cooling effect and are used for moist conditions and hairy areas. Lotions in alcoholic basis can sting if used on broken skin. Ointments are greasy preparations and are much less likely to sensitise and are suitable for chronic dry lesions. Creams and lotions are absorbed into the skin more quickly than ointments or gels.
• Pastes can be used to protect inflamed, lichenified, or excoriated skin.
• Possible contact sensitivity to preservatives or antiseptics is the reason for the range of topical agents.
• Rarely, severe adverse effects can occur on stopping treatment with topical corticosteroids, often after long-term continuous or inappropriate use of moderate to high potency products. To reduce the risks of these events, prescribe the topical corticosteroid of lowest potency needed and ensure patients know how to use it safely and effectively. See MHRA warning - Topical corticosteroids: information on the risk of topical steroid withdrawal reactions.

Unlicensed / Special Manufacture Preparations

• The British Association of Dermatologists (BAD) list of preferred unlicensed dermatological preparations (‘Specials’) is available at the BAD website.
• Use a licensed product wherever available. Consider cost versus benefit of a licensed preparation versus an unlicensed preparation (often in excess of £100). If an unlicensed topical preparation is required, consider only those listed on the BAD list.
• If prescribing specials, prescribe appropriate quantities, as expiry dates are likely to be short for these unlicensed specials products. Do not put the special onto a repeat prescription and ensure that the condition is reviewed regularly.
• If a ‘Specials’ product is required Dermatologists in the East Region have agreed to use only BAD approved ‘Specials’ whenever possible.

Quantities are based on single daily application for 2 weeks in adults:

Quantities are based on twice daily application for 1 week in adults:

Prescribing Notes:

• The choice of emollient should be based on the severity of the condition, patient preference, site of application and preparation cost.
• See general prescribing notes pathway above for information on fire risk with all paraffin based and paraffin free emollients.
• Emollients soothe, smooth and hydrate the skin and are indicated for all dry scaling disorders.
• Emollients should be applied regularly (up to 3-4 times per day) to maintain improvement; and are particularly effective applied after a shower or bath.
• Emollients should be applied in the direction of hair growth.
• Most emollients (apart from white soft paraffin 50%/liquid paraffin 50%) may be used as soap substitutes (hand washing and in bath/shower) by firstly wetting the skin, washing with the cream or ointment, then rinsing off. Alternatively, emollients can be put on the skin before bathing or showering and then washed off to reduce stinging from broken areas.
• If emollients are being applied to the whole body twice daily, children may need 250g per week and adults 500g per week.
• It is more cost-effective to prescribe emollients in large pack sizes and products that come in pump dispensers may be more suitable for long term use in order to reduce the risk of microbial contamination.
• Preparations containing antimicrobials or antiseptics should only be used when treating patients with infected eczema or when antisepsis is required.

Prescribing Notes:

• The choice of emollient should be based on the severity of the condition, patient preference, site of application and preparation cost.
• See general prescribing notes pathway above for information on fire risk with all paraffin based and paraffin free emollients.
• Emollients soothe, smooth and hydrate the skin and are indicated for all dry scaling disorders.
• Emollients should be applied regularly (up to 3-4 times per day) to maintain improvement; and are particularly effective applied after a shower or bath.
• Emollients should be applied in the direction of hair growth.
• Most emollients (apart from white soft paraffin 50%/liquid paraffin 50%) may be used as soap substitutes (hand washing and in bath/shower) by firstly wetting the skin, washing with the cream or ointment, then rinsing off. Alternatively, emollients can be put on the skin before bathing or showering and then washed off to reduce stinging from broken areas.
• If emollients are being applied to the whole body twice daily, children may need 250g per week and adults 500g per week.
• It is more cost-effective to prescribe emollients in large pack sizes and products that come in pump dispensers may be more suitable for long term use in order to reduce the risk of microbial contamination.
• Preparations containing antimicrobials or antiseptics should only be used when treating patients with infected eczema or when antisepsis is required.

Prescribing Notes:

• The choice of emollient should be based on the severity of the condition, patient preference, site of application and preparation cost.
• See general prescribing notes pathway above for information on fire risk with all paraffin based and paraffin free emollients.
• Emollients soothe, smooth and hydrate the skin and are indicated for all dry scaling disorders.
• Emollients should be applied regularly to maintain improvement; and are particularly effective applied after a shower or bath.
• Emollients should be applied in the direction of hair growth.

Prescribing Notes:

• Preparations containing urea are suitable for the treatment of very dry or hyperkeratotic, scaling skin conditions. Balneum plus is suitable for general skin care. Flexitol 10% Urea cream is suitable for general skin care and for the skin on the hands and feet. Dermatonics Once Heel Balm is suitable for use on the soles of the feet.

Prescribing Notes:

• Most emollients (apart from white soft paraffin 50%/liquid paraffin 50%) may be used as soap substitutes (hand washing and in bath/shower) by firstly wetting the skin, washing with the cream or ointment, then rinsing off. Alternatively, emollients can be put on the skin before bathing or showering and then washed off to reduce stinging from broken areas.
• Addition of emollient bath products can make baths slippy.
• A convenient way to apply emulsifying ointment and Hydromol ointment is as “soap balls”, which are made by putting a scoop of the ointment into tubinette or stockinette.
• The presence of antiseptics (e.g. benzalkonium chloride) in emollients can rarely cause allergic reactions or irritation - this should be considered if skin becomes irritated, and an alternative product prescribed.
• Dermol 500 lotion contains an antiseptic, so may be suitable for patients who specifically require an antiseptic soap substitute e.g. infected eczema.

Prescribing Notes:

• Often local specialists recommend once daily application of a topical corticosteroid and if no benefit after review at 7-10 days, will consider a higher potency topical corticosteroid rather than increasing the frequency of application.
• To minimise the risk of side-effects, reduce the frequency of application as the condition settles or step-down potency. The risk of systemic side-effects increases with prolonged use particularly on thin skin surfaces, use in flexures, or use of more potent corticosteroids. Occlusion increases efficacy and side-effects. Only mild corticosteroids should generally be used on the face.
• There is no benefit in changing to a higher percentage strength of topical hydrocortisone. Instead, patients should be moved up the steroid potency ladder i.e. to a moderately potent steroid.
• The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms.
• Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
• Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required.
• Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; apply emollient and corticosteroid at different times of the day.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected.
• Topical corticosteroids should not be used on infected skin unless the infection is being treated
• Topical corticosteroids should not routinely be added to repeat dispensing systems.
• Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
• For the use of topical corticosteroids for lichen sclerosus, see the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• Loss of effect with time (tachyphylaxis) can occur with prolonged use of topical corticosteroids. Intermittent use is preferred to continuous use.

Prescribing Notes:

• Often local specialists recommend once daily application of a topical corticosteroid and if no benefit after review at 7-10 days, will consider a higher potency topical corticosteroid rather than increasing the frequency of application.
• To minimise the risk of side-effects, reduce the frequency of application as the condition settles or step-down potency. The risk of systemic side-effects increases with prolonged use particularly on thin skin surfaces, use in flexures, or use of more potent corticosteroids. Occlusion increases efficacy and side-effects. Only mild corticosteroids should generally be used on the face.
• The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms.
• Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
• Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required.
• Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; apply emollient and corticosteroid at different times of the day.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected.
• Topical corticosteroids should not be used on infected skin unless the infection is being treated
• Topical corticosteroids should not routinely be added to repeat dispensing systems.
• Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
• For the use of topical corticosteroids for lichen sclerosus, see the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• Fludroxycortide tape can be used for localised areas that also require occlusion. It is applied for 12 hours each day. Please note this is a moderately potent steroid.
• Loss of effect with time (tachyphylaxis) can occur with prolonged use of topical corticosteroids. Intermittent use is preferred to continuous use.

Prescribing Notes:

• Often local specialists recommend once daily application of a topical corticosteroid and if no benefit after review at 7-10 days, will consider a higher potency topical corticosteroid rather than increasing the frequency of application.
• To minimise the risk of side-effects, reduce the frequency of application as the condition settles or step-down potency. The risk of systemic side-effects increases with prolonged use particularly on thin skin surfaces, use in flexures, or use of more potent corticosteroids. Occlusion increases efficacy and side-effects. Only mild corticosteroids should generally be used on the face.
• The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms.
• Potent corticosteroids should generally be avoided on the face and skin flexures
• In general, the most potent topical corticosteroids should be reserved for recalcitrant dermatoses such as chronic discoid lupus erythematosus, lichen simplex chronicus, hypertrophic lichen planus, and palmoplantar pustulosis.
• Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
• Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required.
• Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; apply emollient and corticosteroid at different times of the day.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected.
• Topical corticosteroids should not be used on infected skin unless the infection is being treated
• Topical corticosteroids should not routinely be added to repeat dispensing systems.
• Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
• Palms of the hands and soles of the feet may require potent or very potent steroids.
• For the use of topical corticosteroids for lichen sclerosus, see the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• Loss of effect with time (tachyphylaxis) can occur with prolonged use of topical corticosteroids. Intermittent use is preferred to continuous use.

Prescribing Notes:

• Topical steroids should be applied once daily initially, if no benefit after 7-10 days, change to twice daily for a further 7-10 days.
• To minimise the risk of side-effects, reduce the frequency of application as the condition settles or step-down potency. The risk of systemic side-effects increases with prolonged use particularly on thin skin surfaces, use in flexures, or use of more potent corticosteroids. Occlusion increases efficacy and side-effects. Only mild corticosteroids should generally be used on the face.
• The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms.
• Potent corticosteroids should generally be avoided on the face and skin flexures
• In general, the most potent topical corticosteroids should be reserved for recalcitrant dermatoses such as chronic discoid lupus erythematosus, lichen simplex chronicus, hypertrophic lichen planus, and palmoplantar pustulosis.
• Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
• Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required.
• Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; apply emollient and corticosteroid at different times of the day.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected.
• Topical corticosteroids should not be used on infected skin unless the infection is being treated
• Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
• Palms of the hands and soles of the feet may require potent or very potent steroids.
• For the use of topical corticosteroids for lichen sclerosus, see the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• Loss of effect with time (tachyphylaxis) can occur with prolonged use of topical corticosteroids. Intermittent use is preferred to continuous use.
• Patients prescribed very potent topical corticosteroids should be reviewed regularly (at least monthly) and the preparation should not be prescribed on repeat prescription except on specialist advice.

Prescribing Notes:

• There is a risk of severe and fatal burns with all paraffin-based emollients regardless of the paraffin concentration. Data suggest there is also a risk for paraffin-free emollients. Patients who use these products should not smoke or go near naked flames. Emollients can transfer from the skin onto clothing, bedding, dressings, and other fabric. Once there, they can dry onto the fabric and build up over time. In the presence of a naked flame, fabric with emollient dried on is easily ignited. Although emollients are not flammable in themselves or when on the skin, when dried on to fabric they act as an accelerant, increasing the speed of ignition and intensity of the fire.
• Patient clothing and bedding should be changed regularly - preferably daily. Washing clothing or bedding at a high temperature may reduce the emollient build up but not totally remove it.
• Resources are available for health and social care professionals to support the safe use of emollients see MHRA guidance.
• A similar risk may apply for other products which are applied to the skin over large body areas, or in large volumes for repeated use for more than a few days.
• Content is available on the Dermatology pages of the Right Decision Service to provide an accessible resource for primary care practitioners to support the diagnosis and management of patients presenting with common skin conditions.
• The vehicle used in topical preparations influences skin hydration, has a mild anti-inflammatory effect and facilitates penetration of the active component.
• Creams are more cosmetically acceptable than ointments because they are less greasy and easier to apply and may be useful in weeping skin conditions. Gels may be used on the face and scalp while lotions have a cooling effect and are used for moist conditions and hairy areas. Lotions in alcoholic basis can sting if used on broken skin. Ointments are greasy preparations and are much less likely to sensitise and are suitable for chronic dry lesions. Creams and lotions are absorbed into the skin more quickly than ointments or gels.
• Pastes can be used to protect inflamed, lichenified, or excoriated skin.
• Possible contact sensitivity to preservatives or antiseptics is the reason for the range of topical agents.
• Rarely, severe adverse effects can occur on stopping treatment with topical corticosteroids, often after long-term continuous or inappropriate use of moderate to high potency products. To reduce the risks of these events, prescribe the topical corticosteroid of lowest potency needed and ensure patients know how to use it safely and effectively. See MHRA warning - Topical corticosteroids: information on the risk of topical steroid withdrawal reactions.

Unlicensed / Special Manufacture Preparations

• The British Association of Dermatologists (BAD) list of preferred unlicensed dermatological preparations (‘Specials’) is available at the BAD website.
• Use a licensed product wherever available. Consider cost versus benefit of a licensed preparation versus an unlicensed preparation (often in excess of £100). If an unlicensed topical preparation is required, consider only those listed on the BAD list.
• If prescribing specials, prescribe appropriate quantities, as expiry dates are likely to be short for these unlicensed specials products. Do not put the special onto a repeat prescription and ensure that the condition is reviewed regularly.
• If a ‘Specials’ product is required Dermatologists in the East Region have agreed to use only BAD approved ‘Specials’ whenever possible.

Corticosteroid creams

Quantities are based on single daily application for 2 weeks. Estimates are based on the number of adult finger tips units (FTUs) of cream to treat the area. 2 FTUs are about the same as 1g of topical steroid.

(*) Qty = Estimated prescribable quantity of corticosteroid cream/ointment.


Quantities are based on twice daily application for 1 week in a child 12-18 years; smaller quantities will be required for children under 12 years:

Prescribing Notes:

• The choice of emollient should be based on the severity of the condition, patient preference, site of application and preparation cost.
• See general prescribing notes pathway above for information on fire risk with all paraffin based and paraffin free emollients.
• Emollients soothe, smooth and hydrate the skin and are indicated for all dry scaling disorders.
• Emollients should be applied regularly (up to 3-4 times per day) to maintain improvement; and are particularly effective applied after a shower or bath.
• Emollients should be applied in the direction of hair growth.
• Most emollients (apart from white soft paraffin 50%/liquid paraffin 50%) may be used as soap substitutes (hand washing and in bath/shower) by firstly wetting the skin, washing with the cream or ointment, then rinsing off. Alternatively, emollients can be put on the skin before bathing or showering and then washed off to reduce stinging from broken areas.
• If emollients are being applied to the whole body twice daily, children may need 250g per week and adults 500g per week.
• It is more cost-effective to prescribe emollients in large pack sizes and products that come in pump dispensers may be more suitable for long term use in order to reduce the risk of microbial contamination.
• Preparations containing antimicrobials or antiseptics should only be used when treating patients with infected eczema or when antisepsis is required.

Prescribing Notes:

• The choice of emollient should be based on the severity of the condition, patient preference, site of application and preparation cost.
• See general prescribing notes pathway above for information on fire risk with all paraffin based and paraffin free emollients.
• Emollients soothe, smooth and hydrate the skin and are indicated for all dry scaling disorders.
• Emollients should be applied regularly (up to 3-4 times per day) to maintain improvement; and are particularly effective applied after a shower or bath.
• Emollients should be applied in the direction of hair growth.
• Most emollients (apart from white soft paraffin 50%/liquid paraffin 50%) may be used as soap substitutes (hand washing and in bath/shower) by firstly wetting the skin, washing with the cream or ointment, then rinsing off. Alternatively, emollients can be put on the skin before bathing or showering and then washed off to reduce stinging from broken areas.
• If emollients are being applied to the whole body twice daily, children may need 250g per week and adults 500g per week.
• It is more cost-effective to prescribe emollients in large pack sizes and products that come in pump dispensers may be more suitable for long term use in order to reduce the risk of microbial contamination.
• Preparations containing antimicrobials or antiseptics should only be used when treating patients with infected eczema or when antisepsis is required.

Prescribing Notes:

• The choice of emollient should be based on the severity of the condition, patient preference, site of application and preparation cost.
• See general prescribing notes pathway above for information on fire risk with all paraffin based and paraffin free emollients.
• Emollients soothe, smooth and hydrate the skin and are indicated for all dry scaling disorders.
• Emollients should be applied regularly to maintain improvement; and are particularly effective applied after a shower or bath.
• Emollients should be applied in the direction of hair growth.

Prescribing Notes:

• Preparations containing urea are suitable for the treatment of very dry or hyperkeratotic, scaling skin conditions. Balneum plus is suitable for general skin care. Flexitol 10% Urea cream is suitable for skin lesions on the hands and feet. Dermatonics Once Heel Balm is suitable for use on the soles of the feet.

Prescribing Notes:

• Most emollients (apart from white soft paraffin 50%/liquid paraffin 50%) may be used as soap substitutes (hand washing and in bath/shower) by firstly wetting the skin, washing with the cream or ointment, then rinsing off. Alternatively, emollients can be put on the skin before bathing or showering and then washed off to reduce stinging from broken areas.
• Addition of emollient bath products can make baths slippy.
• A convenient way to apply emulsifying ointment and Hydromol ointment is as “soap balls”, which are made by putting a scoop of the ointment into tubinette or stockinette.
• The presence of antiseptics (e.g. benzalkonium chloride) in emollients can rarely cause allergic reactions or irritation - this should be considered if skin becomes irritated, and an alternative product prescribed.
• Dermol 500 lotion contains an antiseptic, so may be suitable for patients who specifically require an antiseptic soap substitute e.g. infected eczema.
• Emollient bath and shower products or soap substitutes with antiseptic (Dermol 500 lotion) should be used to reduce staphylococcal load in eczematous patients.

Prescribing Notes:

• Often local specialists recommend once daily application of a topical corticosteroid and if no benefit after review at 7-10 days, will consider a higher potency topical corticosteroid rather than increasing the frequency of application.
• To minimise the risk of side-effects, the smallest effective amount should be used, reducing strength and frequency of application as the condition settles. The risk of systemic side-effects increases with prolonged use particularly on thin, inflamed or raw skin surfaces, use in flexures, or use of more potent corticosteroids. Occlusion increases efficacy and side-effects. Only mild corticosteroids should generally be used on the face.
• There is no benefit in changing to a higher percentage strength of topical hydrocortisone. Instead, patients should be moved up the steroid potency ladder i.e. to a moderately potent steroid.
• The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms.
• Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
• Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required. The occlusive effect of ointments increases penetration of the corticosteroid.
• Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; apply emollient and corticosteroid at different times of the day.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected.
• Topical corticosteroids should not be used on infected skin unless the infection is being treated.
• Topical corticosteroids should not routinely be added to repeat dispensing systems.
• Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
• For the use of topical corticosteroids for lichen sclerosus, see the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• Loss of effect with time (tachyphylaxis) can occur with prolonged use of topical corticosteroids. Intermittent use is preferred to continuous use.
• Antibacterials and antifungals with corticosteroids may have a role if there is associated infection.

Prescribing Notes:

• Often local specialists recommend once daily application of a topical corticosteroid and if no benefit after review at 7-10 days, will consider a higher potency topical corticosteroid rather than increasing the frequency of application.
• To minimise the risk of side-effects, the smallest effective amount should be used, reducing strength and frequency of application as the condition settles. The risk of systemic side-effects increases with prolonged use particularly on thin, inflamed or raw skin surfaces, use in flexures, or use of more potent corticosteroids. Occlusion increases efficacy and side-effects. Only mild corticosteroids should generally be used on the face.
• The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms.
• Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
• Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required. The occlusive effect of ointments increases penetration of the corticosteroid.
• Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; apply emollient and corticosteroid at different times of the day.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected.
• Topical corticosteroids should not be used on infected skin unless the infection is being treated.
• Topical corticosteroids should not routinely be added to repeat dispensing systems.
• Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
• For the use of topical corticosteroids for lichen sclerosus, see the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• Fludroxycortide tape can be used for localised areas that also require occlusion. It is applied for 12 hours each day. Please note this is a moderately potent steroid.
• Loss of effect with time (tachyphylaxis) can occur with prolonged use of topical corticosteroids. Intermittent use is preferred to continuous use.
• Antibacterials and antifungals with corticosteroids may have a role if there is associated infection.

Prescribing Notes:

• Often local specialists recommend once daily application of a topical corticosteroid and if no benefit after review at 7-10 days, will consider a higher potency topical corticosteroid rather than increasing the frequency of application.
• To minimise the risk of side-effects, the smallest effective amount should be used, reducing strength and frequency of application as the condition settles. The risk of systemic side-effects increases with prolonged use particularly on thin, inflamed or raw skin surfaces, use in flexures, or use of more potent corticosteroids. Occlusion increases efficacy and side-effects. Only mild corticosteroids should generally be used on the face.
• The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms.
• Potent corticosteroids should generally be avoided on the face and skin flexures.
• In general, the most potent topical corticosteroids should be reserved for recalcitrant dermatoses such as chronic discoid lupus erythematosus, lichen simplex chronicus and hypertrophic lichen planus.
• Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
• Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required. The occlusive effect of ointments increases penetration of the corticosteroid.
• Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; apply emollient and corticosteroid at different times of the day.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected.
• Topical corticosteroids should not be used on infected skin unless the infection is being treated.
• Topical corticosteroids should not routinely be added to repeat dispensing systems.
• Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
• Palms of the hands and soles of the feet may require potent or very potent steroids.
• For the use of topical corticosteroids for lichen sclerosus, see the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• Loss of effect with time (tachyphylaxis) can occur with prolonged use of topical corticosteroids. Intermittent use is preferred to continuous use.
• Antibacterials and antifungals with corticosteroids may have a role if there is associated infection.