Steroids are best used as a circuit breaker, where they are applied for a few weeks before being gradually weaned off. These products should be used alongside emollients with the goal of switching to emollient-only management after the circuit breaker period.
July 5, 2023
Steroids are the most common medication prescribed for the management of AD. They work by suppressing inflammation in the skin and are particularly useful in the management of disease flares.
In AD we use a specific family of steroids called corticosteroids. These drugs are based on cortisol, a naturally occurring hormone produced by the body with many functions including suppressing the body's immune system and inflammation.
Steroids are useful tools in the management of AD as they tackle one of the key features of AD, inflammation. Steroids are best used as a circuit breaker, where they are applied for a few weeks before being gradually weaned off. During the period of use inflammation and the immune cells in the skin are suppressed, this prevents further water loss and improves the skin's barrier integrity. These products should be used alongside emollients with the goal of switching to emollient-only management after the circuit breaker period.
Steroids do have some risks associated with regular use including skin thinning and altering the skin colour (hypo/hyperpigmentation). This is why they shouldn’t be used daily for prolonged periods (>6 weeks).
Perfect use for flare management
Phase 1 - Daily for 2 weeks
Phase 2 - Every other day for 2 weeks
Phase 3 - Twice weekly for 2 weeks
For milder flares you can use shorter regimes, as you get to know your skin you’ll figure out what works best for you. There is also no evidence that using a steroid cream twice a day is more effective than once a day use.
These products come in varying strengths ranging from mild potency (hydrocortisone) to very potent (Dermovate/Clobetasol propionate). It is important to avoid using strong/potent steroids on delicate skin (eyelids, face) as these areas are more prone to skin thinning. Conversely using weak/mild potency steroids on thick skin (hands and scalp) are unlikely to have any effect.
Common pitfalls of topical corticosteroid use
1. Not using a strong enough product - if you use a product that is too weak you're not going to be able to effectively suppress the inflammation in the skin, meaning you'll need to use the product for longer and may never achieve significant inflammation suppression.
2. Stopping suddenly - it's always best to taper off your use vs stopping suddenly, if you do stop suddenly and your skin barrier hasn't sufficiently repaired then you're likely to re-flare and undo all of your hard work.
3. Not using an emollient - steroids can very quickly suppress inflammation and settle eczema symptoms. Unfortunately, this can falsely reassure you that the problem with the skin is fixed - as we know skin dryness and compromised barrier function are the core drivers of eczema/AD and steroids only suppress inflammation. Using an emollient alongside a steroid ensures you rehydrate and strengthen the skin while the steroids calm the inflammation.