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TreatmentFoundationalBNF 13.4

Topical corticosteroids (potency, use)

TCS · steroid creams / ointments · UK potency ladder

Topical corticosteroids are the cornerstone of inflammatory-skin-disease treatment, classified in the UK by potency (mild → moderate → potent → super-potent). They act via the cytoplasmic glucocorticoid receptor to suppress pro-inflammatory transcription, reduce mediator release and induce vasoconstriction. Despite extensive evidence of safety when used appropriately, the phenomenon of topical-steroid withdrawal (TSW) and high-profile media attention require careful counselling. NICE CG57 / NG198 / CKS guidance and the 2024 UK joint TSW statement support a stepped approach by indication, site, age and severity.

CurrentLast reviewed 18 May 2026

Mechanism

  • Bind cytosolic glucocorticoid receptor → translocate to nucleus → transactivation of anti-inflammatory genes (lipocortin-1) and transrepression of pro-inflammatory genes (NF-κB, AP-1).
  • Effects:
    • Vasoconstriction (acute).
    • Anti-inflammatory: reduced cytokines, chemokines, prostaglandins.
    • Anti-proliferative: keratinocyte and fibroblast suppression.
    • Immunosuppressive: Langerhans cell, T-cell function suppression.
  • Lipid solubility, vehicle (ointment vs cream vs lotion vs foam vs gel), occlusion and skin permeability determine absorption.

UK potency classification

Potency (UK)ExamplesTypical uses
Mild (Group VII)Hydrocortisone 0.5-1-2.5%Face, flexures, eyelids, infants; mild eczema.
Moderate (Group V-VI)Clobetasone butyrate 0.05% (Eumovate); fluocinolone 0.0025-0.025%Mild-moderate eczema; older children / adults; non-face sites.
Potent (Group III-IV)Betamethasone valerate 0.1% (Betnovate); mometasone furoate 0.1% (Elocon); fluticasone propionate 0.05% (Cutivate); hydrocortisone butyrate 0.1% (Locoid)Moderate-severe eczema; lichen planus; psoriasis (non-face); contact dermatitis.
Super-potent (Group I)Clobetasol propionate 0.05% (Dermovate); halobetasol 0.05%Severe disease; palmoplantar; lichen sclerosus; BP (Joly protocol); discoid lupus; keloid.

Note: UK classification is the inverse of US classification (US Group I = strongest, Group VII = weakest).

Dosing and FTU concept

Finger-tip unit (FTU) — quantity of cream / ointment expressed from a tube with a 5-mm nozzle and applied along the length of the adult index finger (~0.5 g for an adult).

  • 1 FTU covers an area equivalent to 2 adult palms.
  • Typical adult adult body coverage:
    • Face / neck: 2.5 FTU
    • One arm + hand: 4 FTU
    • One leg + foot: 8 FTU
    • Trunk front: 7 FTU
    • Trunk back including buttocks: 7 FTU
  • Apply 1-2× daily.
  • Tapered "step-down" approach: control with potent; maintain with twice-weekly application.

Safety considerations

  • Local effects:
    • Skin atrophy, striae.
    • Hypopigmentation (especially Fitzpatrick III-VI).
    • Telangiectasia.
    • Acneiform / rosacea-like eruption (perioral dermatitis).
    • Hypertrichosis.
    • Increased infection susceptibility (especially eyelid HSV with steroids).
  • Systemic effects (rare; with extensive / prolonged super-potent use):
    • HPA-axis suppression.
    • Cushing's syndrome (children, occlusion).
    • Growth retardation (children).
    • Glaucoma / cataract (periocular).
  • Topical steroid withdrawal (TSW):
    • Recognised entity following prolonged inappropriate use, often face / genitals.
    • Erythema, burning, papules within weeks of cessation.
    • UK joint TSW statement (National Eczema Society, British Dermatological Nursing Group and BAD); supportive management and careful review of differential diagnoses.
  • Tachyphylaxis: reduced clinical response with continuous use; rest periods restore effect.

Practical use

  • Match potency to disease severity, site and patient age.
  • Face / flexures / eyelids: prefer mild-moderate; reserve super-potent for short, defined courses (e.g. 2 weeks).
  • Avoid super-potent in children, occluded sites unless specialist supervision.
  • Always combine with bland emollient regimen.
  • Counsel on FTU dosing, expected duration, taper.
  • Treat infection (HSV, S. aureus) before continuing TCS.
  • Pregnancy: TCS generally safe; high-potency / large body-surface area use linked to small risk of low birth weight; minimise where possible.
  • Cancer-related skin care:
    • EGFRi-related rash: mild-moderate TCS adjunct.
    • ICI-related dermatitis: mid-potent TCS for G1-G2; oral CS for G3+.
    • Radiation dermatitis: mild-moderate TCS; emerging biologics.
  • Address TSW concerns with empathy; supportive evidence-based reassurance.

References

  1. Goa KL. Clinical pharmacology and pharmacokinetic properties of topically applied corticosteroids. Drugs. 1988;36(Suppl 5):51-61.
  2. National Eczema Society, British Dermatological Nursing Group and British Association of Dermatologists. Topical steroid withdrawal: joint statement. 2024.
  3. Long CC, Finlay AY. The finger-tip unit — a new practical measure. Clin Exp Dermatol. 1991;16:444-447.
  4. NICE CG57. Atopic eczema in under 12s: diagnosis and management. London: NICE; 2007 (last updated 22 September 2025).
  5. NICE NG198. Acne vulgaris: management. London: NICE; 2021 (last updated 30 April 2026).
  6. Sheary B et al. Topical corticosteroid withdrawal in a patient with atopic eczema. Australas J Dermatol. 2018;59:218-220.

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