Steve Titmarsh considers how topical corticosteroids can be used and what advice pharmacists can give patients so they can gain the greatest benefit…

Topical corticosteroids such as hydrocortisone can be used to relieve symptoms and suppress signs of the disorders such as inflammatory skin conditions other than those caused by infection. They are usually used when other products such as emollients are not effective.¹

Hydrocortisone cream 1% w/w can be used as a topical anti-inflammatory for the treatment of irritant dermatitis, contact allergic dermatitis, insect bite reactions and mild-to-moderate eczema.² It exerts its effect through a wide range of actions, including anti-inflammatory, antimitotic and immunosuppressive effects.

It reduces the vascular component of the inflammatory response and the formation of inflammatory fluid and cellular exudates. It also acts to reduce the release of mediators involved in the inflammatory response by stabilising mast cells, for example. The drug also acts as a vasoconstrictor, which may contribute to its anti-inflammatory effect.²

Use with caution or not at all…

Hydrocortisone cream should not be used for bacterial, viral or fungal (candidal or dermatophyte) skin infections.

Topical steroids can mask or aggravate skin infections such as impetigo, tinea, herpes simplex, malassezia folliculitis and molluscum contagiosum.³ And they should not be used on the eyes or face, the anogenital region, or broken or infected skin, including cold sores, acne and athlete's foot.²

Additionally they are not suitable for allergic skin reactions, including temporary red or raised areas on the skin (such as short lived ‘wheal and flare’ reactions); or conditions involving the deeper skin layers, such as granulomas or psoriasis.⁴

Topical hydrocortisone should not be applied for long periods of time, particularly on the face, and for children and infants where it should usually only be used for a maximum of seven days as there is potential for overdose.

OTC topical hydrocortisone cortisone preparations should not be used for more than a week at a time or to treat children under 10 years old without advice from a doctor.⁵

Short-term application of topical hydrocortisone, used according to instructions, rarely causes problems.⁶However, long-term continuous use or inappropriate use can result in rebound flares, with symptoms such as redness of the skin, burning sensation and itchiness,⁷ when treatment is stopped.

This is more likely with moderate to high potency corticosteroids such as betamethasone, clobetasone and hydrocortisone butyrate, and when delicate areas such as the face and flexures have been treated.

To provide some context, in a report in 2021 the Medicines and Healthcare products Regulatory Agency (MHRA) identified 55 reports as ‘probable topical steroid withdrawal reactions’ in the Yellow Card database and a further 62 cases of ‘possible topical steroid withdrawal reactions’.

Thirty probable cases related to betamethasone with 12 associated with hydrocortisone. However, a higher number of cases for an individual medicine should not be interpreted as it being a higher risk. Some cases may be listed for multiple steroids as often patients are switched from one product to another in increasing strength to try and resolve their symptoms.⁷

The MHRA advises that the lowest potency topical corticosteroid needed should be used. For patients who are currently on long-term topical corticosteroid treatment, prescribers should consider reducing potency or frequency of application (or both).⁸

Health care professionals should also be vigilant for the signs and symptoms of topical corticosteroid withdrawal reactions and review the position statement from the National Eczema Society and British Association of Dermatologists.^8,9

OTC topical hydrocortisone should not be used under an occlusive dressing or by anyone allergic to any of the formulation’s ingredients.²

Advice for use OTC

Topical corticosteroid preparations should be applied no more frequently than twice daily: once daily is often sufficient.⁹

Just enough should be applied to cover the affected area(s). The so-called ‘fingertip unit’ can be used to judge how much cream is needed for a given area of skin. A fingertip unit is the distance from the tip of an adult index finger to the first crease.

One fingertip unit (approximately 500mg from a tube with a standard 5mm diameter nozzle) is sufficient to cover an area that is twice that of the flat adult handprint (palm and fingers).⁸

Several minutes should be allowed between application of topical corticosteroids and emollients if they are also being used in conjunction. And 8 to 12 hours should be left between applications if it is being used twice a day.⁸

Healthcare professionals should advise patients using topical steroids (see also Box 1):⁸

• How much to apply – as under-use can prolong treatment duration
• How long to use for, especially on sensitive areas
• To always apply as instructed and read the patient information leaflet
• To seek medical advice before using on a new body area, as some areas of the body are more prone to side-effects
• To return for medical advice if their skin condition worsens while using a topical corticosteroid, and advise them when it would be appropriate to re-treat without a consultation
• If their skin worsens within two weeks of stopping a topical corticosteroid, treatment should not be started again without consulting their doctor unless they have previously been advised to do so.

Box 1. How to use hydrocortisone skin cream or ointment¹⁰

• Wash and dry your hands and then squeeze out the right amount
• Spread the cream or ointment in a thin layer over the area of irritated skin
• Carefully smooth it into your skin in the direction the hair grows until it disappears
• Use the cream on all the irritated skin, not just the worst areas
• Be careful not to get the cream into broken skin or cuts
• Wash your hands afterwards (unless you are treating the skin on your hands)

References

1. British National Formulary. Topical corticosteroids (https://bnf.nice.org.uk/treatment-summaries/topical-corticosteroids; accessed February 2023).
2. Pinewood Healthcare. Hydrocortisone 1% w/w cream (www.medicines.org.uk/emc/product/4600/smpc#gref; accessed January 2023).
3. DermNet. Topical steroid (https://dermnetnz.org/topics/topical-steroid; accessed February 2023).
4. Package leaflet: Information for the user hydrocortisone 1% W/W cream 1% hydrocortisone (www.medicines.org.uk/emc/files/pil.4600.pdf; accessed February 2023).
5. NHS. Hydrocortisone for skin (www.nhs.uk/medicines/hydrocortisone-skin-cream; accessed February 2023).
6. Patient.info. Hydrocortisone for mild inflammatory skin conditions (https://patient.info/medicine/hydrocortisone-for-mild-inflammatory-skin-conditions-dermacort-hc45-mildison; accessed January 2023).
7. The Medicines and Healthcare products Regulatory Agency (MHRA). Research and analysis: Topical steroid withdrawal reactions: a review of the evidence www.gov.uk/government/publications/topical-steroid-withdrawal-reactions-a-review-of-the-evidence/topical-steroid-withdrawal-reactions-a-review-of-the-evidence; accessed February 2023).
8. British National Formulary. Hydrocortisone (https://bnf.nice.org.uk/drugs/hydrocortisone/#directions-for-administration; accessed February 2023).
9. National Eczema Society and British Association of Dermatologists joint position statement on Topical Steroid Withdrawal January 2021 (https://eczema.org/wp-content/uploads/Topical-Steroid-Withdrawal-position-statement.pdf; accessed February 2023).
10. NHS. Hydrocortisone for skin (www.nhs.uk/medicines/hydrocortisone-skin-cream; accessed February 2023).