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Topical steroids

Topical Steroids

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Resistance to treatment is known as tachyphylaxis which is a common problem with prolonged use of topical corticosteroids. Topical steroids holiday break like intermittent pulse dosing of 1 week of rest for alternative days are done for difficult chronic skin conditions where long term steroids are to be used.

Thinning of the epidermis can occur within 7 days of use of superpotent topical steroids. After 3weeks of potent topical steroid use, all the layers of the epidermis are reduced in thickness by about one half. The thinning of the epidermis, particularly the stratum corneum, impairs the barrier function of the epidermis, thus increasing transepidermal water loss and skin irritancy.

Yes, some patients present with mild dermatitis respond well to topical steroids. However, when the topical steroid discontinues the symptoms quickly return and are more profound. Thus, the patent is reluctant to discontinue the steroid despite the perpetuation the syndrome.

The topical steroid addiction syndrome is a frustrating side effect that occurs most commonly on the face or anogenital skin. Topical moisturizers, soaps, sunscreens, and makeup are poorly tolerated. A patient complains of burning and stinging as a result of thinning of the stratum corneum and epidermis. Treatment is discontinuation of the topical steroid medication. The patients should be warned that the symptoms will flare and may take weeks or even months to completely clear.

The symptoms produced by dermatophyte infections are due to the body's immune response to the offending fungal organism. Topical steroids decrease the inflammatory response and initially alleviate the symptoms. In decreasing the body's defense mechanisms, however, they allow the organism to proliferate, alter the typical clinical picture, and delay the correct diagnoses.

Local cutaneous side effects are the most common problem associated with topical steroids. They may develop quickly with potent topical steroids, especially when applied to thin-skinned or folds of the body. Therefore prolonged use of potent steroids is not recommended.

Within 1 to 3 weeks of using superpotent topical steroids, the dermal volume is measurably reduced. This is due to decreased fibroblast production of dermal ground substance primarily hyaluronic acid and decreased dermal water content. Abnormal synthesis of collagen and elastin results in dermal atrophy, skin fragility, striae, telangiectasias, poor vascular support with skin purpura, and decreased wound healing.

Periorificial dermatitis is frequently associated with the inappropriate use of topical steroids. It occurs most commonly in adult, a fair-skinned Caucasian woman who has a family history of rosacea. The rash is characterized by inflammatory follicular papules and pustules with a background of erythema and scaling located on the chin, perioral, and perinasal skin, and less commonly on the eyelids. Most patients respond well to discontinuation of the topical steroids and oral antibiotics of the tetracycline class for 4 to 6 weeks. Some patients flare when the steroid is discontinued, and some have recurrences.

Yes. Contact dermatitis can either be irritant or allergic. Irritant reactions are frequent and most commonly are due to propylene glycol in the topical preparation. The patient complains of immediate burning or stinging after application.
True allergic contact dermatitis should be suspected when a patient does not respond predictably with appropriate topical steroid therapy. It can be due to the vehicle, preservative, fragrance, or the steroid molecule itself, and there is often cross-reactivity. Contact allergies are most common with hydrocortisone, budesonide, and tixocortol and are least common with betamethasone, clobetasol, mometasone, and triamcinolone. Patch testing may be needed to identify the allergen.

List some common mistakes that are made when prescribing a topical steroid

  • Incorrect diagnosis.
  • Failure to consider coexisting diseases.
  • Recommending a product that is either too potent or too weak.
  • Prescribing excessive or inadequate amount.
  • Recommending the wrong vehicle.
  • Failure to demonstrate proper application techniques.
  • Using the medication for too long or too short a period of time.
  • Use of air-tight occlusion.
  • Failure to recognize and monitor for topical steroid side effects.
  • Lack of timely follow-up to disease and treatment regimen.

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