Guide to topical corticosteroid potency

This page explains the difference between potency and concentration, looking at the different potencies of topical steroid compounds and how these may be altered due to formulation. It also covers the basic principles of managing potency of topical steroids in clinical practice.

Learning objectives

By the end of this page you will be able to:

  • Explain what is meant by topical corticosteroid potency.
  • Explain the differences between the UK system of classification and US system.
  • List the potency of different topical steroid compounds based on UK ranking.
  • State the basic principles of managing potency of topical steroids in clinical practice.
  • Describe the individual patient considerations that should be made when deciding the potency of topical steroid to prescribe.

Estimated completion time: 15 minutes

 

 

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Potency and concentration

Topical corticosteroid potency is related to the glucocorticoid receptor alpha binding process, which is an intrinsic drug property (based on vasoconstrictive assay) and not the same as drug concentration.  go to reference
Clark (2011)

 

muddle Product labelling always includes drug concentration and not potency.

Concentration refers to the amount of steroid molecule in the formulation (for example clobetasone butyrate 0.05%), which does not describe the powerfulness or potency of the topical steroid (clobetasone butyrate is moderate potency, whereas, 1% Hydrocortisone is mild potency). Potency is an intrinsic property of the drug and not the same thing as concentration.



myth It is sometimes incorrectly thought that topical steroid drug concentration relates to potency.

for example

Betamethasone Diproprionate 0.05% is more potent than Hydrocortisone 1%.

Note the concentration of Betamethasone Dipropionate 0.05% is one-fifth of the concentration of Hydrocortisone 1%.

 

 

Classification of topical steroid potency

Topical steroids are classified by potency (or strengths) of the individual topical steroid molecules. Potency can be altered by drug concentration and formulation (nature of vehicle used). go to reference
Berth-Jones (2010)

Potency ranking is essential to predict drug response and possible adverse effects.

 

 

Topical corticosteroids are ranked differently in the UK and US.

 

Topical steroid ranking in the UK

UK Flag In the UK, topical steroids are ranked on a four-point scale, devised by The British National Formulary:

  • Mild
  • Moderate
  • Potent
  • Very potent
go to reference
(Joint Prescribing Committee, 20111)

It is important to be aware that topical steroids with similar names may have different potencies.

 

Myth It is often incorrectly believed that hydrocortisone is always classed as a mild potency topical steroid.
  for example

Hydrocortisone is often presumed to be a mild potency topical steroid, however there are several different potencies for Hydrocortisone:
  • Alphaderm® and Calmurid HC® both contain 1% Hydrocortisone and urea and are classified as moderate topical steroids.
  • Hydrocortisone butyrate 0.1% (Locoid® and Locoid Crelo®) are potent topical steroids.

 

 

 

ranking of topical steroids

 

Topical steroid ranking in the US

usa flag In the US, topical steroids are ranked using a 7-point scale.


A difference between the UK and US is that both drug concentration and formulation are considered in the US potency ranking.


go to reference
Ference (2009)

 

 

Class Potency Example Formulation
Class 1 Ultra high Clobetasol propionate 0.05% All formulations
Class 11 High Betamethasone dipropionate 0.05% Ointment
Class 111 Medium to high Betamethasone dipropionate 0.05% Cream
Class 1V and V Medium Mometasone furoate 0.1%
Hydrocortisone butyrate 0.1%
All formulations
Ointment
Class V1 Low Hydrocortisone butyrate 0.1%
Alclometasone diproprionate 0.05%
Cream
All formulations
Class V11 Least potent Hydrocortisone 1 % and 2.5% All formulations

go to reference Table adapted from Ference (2009)

 

 

 

Know your potency (based on UK ranking for topical steroid compounds)

go to reference Joint Formulary Committee (20111)

know your potency

myth Some people think that Fludroxycortide is a potent steroid, as it is a tape. However, impregnated topical steroid tape does not increase potency.

 

For full details on the generic and branded topical steroid products containing the topical steroid compound in the steps above, please visit:

  • The British National Formulary (BNF 63) at www.bnf.org, or,
  • The Monthly Index of Medical Specialties (MIMS) at www.mims.co.uk
    MIMS has a helpful chart of therapeutic potencies and formulations of topical steroids.

Please note these websites both require registration for full access.

 

 Potency differences

* Note topical steroid compounds, which have altered potencies due to formulation:

Mild

Hydrocortisone – Alphaderm® (combined with 10% urea, increasing potency to moderate); Calmurid HC® (combined with 10% urea and 5% lactic acid, increasing potency to moderate)

Potent

Betamethasone esters - Betnovate-RD® (1 in 4 dilution, reducing potency to moderate)

Diflucortolone valerate - Nerisone Forte® (increase in concentration to 0.3%, increasing potency to very potent)

Fluocinolone acetonide – Synalar 1 in 4 dilution® (1 in 4 dilution, reducing potency to moderate); Synalar 1 in 10 dilution® (1 in 10 dilution, reducing potency to mild)

 

 

Clinical practice and potency

The basic principles of managing potency of topical steroids in clinical practice are:

  • To use the least potent topical corticosteroid to produce the most effective treatment.
go to reference
Clark (2011)
  • To use topical steroids as part of a stepped-care programme, matching potency to severity of disease, as described in NICE guidelines.
go to reference
NICE (2004)
go to reference
NICE (2007)
go to reference
Thomas, Armstrong
and Avery (2002)
  • In atopic eczema, short bursts of a potent topical steroid is as effective as prolonged use of a mild topical steroid.
go to reference
Clark (2011)

 

In clinical practice, it is essential to consider the individual patient when making clinical decisions on which potency of topical steroid to prescribe. This will depend on:

go to linkAge

Age

Children require lower potencies than adults, as infants and small children have an increased risk for side effects with any potency topical steroid because of their increased skin surface to body mass ratio. go to reference
Del Rosso and Friedlander (2005)

 

for example

The potency of topical corticosteroids should be tailored to the severity of the child’s atopic eczema, which may vary according to body site. They should be used as follows: go to reference
NICE (2007)
  • Use mild potency for mild atopic eczema.
  • Use moderate potency for moderate atopic eczema.
  • Use potent for severe atopic eczema.
  • Use mild potency for the face and neck, except short-term (3-5 days) use of moderate potency for severe flares.
  • Use moderate or potent preparations for short periods only (7-14 days) for flares in vulnerable sites, such as axillae and groin.
  • Do not use very potent preparations in children without specialist dermatological advice.

Note: Child refers to 12 years and under

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go to linkArea of body treated

Area of body treated

Patients will often require a selection of topical steroid potencies to treat different areas of the body. Steroids are absorbed at different rates from different parts of the body. A steroid that works on the face may not work on the palm. But a potent steroid may cause side effects on the face.

for example go to reference
Dermnet NZ (20112)
  • Eyelids and genitals absorb 30%
  • Face absorbs 7%
  • Armpit absorbs 4%
  • Forearm absorbs 1%
  • Palm absorbs 0.1%
  • Genitals absorb 30%
  • Sole absorbs 0.05%

 

Where the skin is thin (the face and genitals) and in body folds (as this acts as occlusion), a mild or moderate potency should be used.

Where the skin is thick, on the palms and soles, potent and very potent topical steroids can be used.


steroid rate absorption

 Close

go to linkChoice of formulation for area of body treated

Choice of formulation for area treated

Formulation (the topical steroid vehicle) is also important for application to different body sites, different skin conditions and for cosmetic acceptability to the patient.

 

For further information on choice of formulation for area treated, please go to:

go to link Topical steroid formulation and vehicle choices

 Close

go to linkOcclusion

Occlusion

Occlusion of topical steroids by dressings, bandages and body wraps increases absorbency into the skin. A lower potency topical steroid should be used under occlusion. The use of occlusive techniques may well increase the potency of the steroid required to achieve disease remission. go to reference
Fitzmaurice, Pugashetti and Gattu (2008)

 

For further information on occlusion, please go to:

go to link Topical steroid formulation and vehicle choices

 Close

go to link Targeted application

Targeted application

Targeted application by the use of impregnated surgical tape can be achieved by applying tape to the area for treatment and leaving in place for 12 hours. This provides a dual effect of targeted topical steroid application with occlusion.

 

For further information on targeted application, please go to:

go to link Topical steroid formulation and vehicle choices

 Close

Click on the links above for further information on each of these.

 

Reference

Clark C (2011) Topical corticosteroids. Exchange – National Eczema Society Members’ Magazine; 141:14-17.

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Reference

Berth-Jones J (2010) Topical Treatments used in the management of skin disease. In Burns T, Breathnach S, Cox N, Griffiths C (eds). Rook’s Textbook of Dermatology – 8th Edition. Vol 4. Chapter 73 1-23. Oxford: Wiley-Blackwell.

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Reference

Joint Formulary Committee (20111) Topical corticosteroids. British National Formulary 62: 13.4. Available at: http://bnf.org/bnf/bnf/current/5837  [Accessed 16 December 2011]

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Reference

Ference JD, Last AR (2009) Choosing topical corticosteroids.American Family Physician; 79(2): 135-140.

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Reference

Ference JD, Last AR (2009) Choosing topical corticosteroids.American Family Physician; 79(2): 135-140.

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Reference

Joint Formulary Committee (20111) Topical corticosteroids. British National Formulary 62: 13.4. Available at: http://bnf.org/bnf/bnf/current/5837  [Accessed 16 December 2011]

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Reference

Clark C (2011) Topical corticosteroids. Exchange – National Eczema Society Members’ Magazine; 141:14-17.

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Reference

Clark C (2011) Topical corticosteroids. Exchange – National Eczema Society Members’ Magazine; 141:14-17.

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Reference

National Institute for Health and Clinical Excellence (2004) TA81 Atopic eczema dermatitis-topical steroids guidance. Available from: http://guidance.nice.org.uk/TA81/Guidance/pdf/English  [Accessed 16 December 2011]

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Reference

National Institute for Health and Clinical Excellence (2007) CG 57 Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years – Full Guidance. [Online]. Available from http://www.nice.org.uk/CG57  [Accessed 16 December]

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Reference

Thomas KS, Armstrong S, Avery A et at (2002) Randomized controlled trial of short bursts of a potent topical corticosteroid versus prolonged use of a mild preparation for children with mild to moderate atopic eczema. British Medical Journal; 324: 1-7.

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Reference

Del Rosso J, Friedlander SF (2005) Corticosteroids: options in the era of steroid-sparing therapy. Journal of American Academy of Dermatology; 53(1): S50-S58.

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Reference

National Institute for Health and Clinical Excellence (2007) CG 57 Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years – Full Guidance. [Online]. Available from http://www.nice.org.uk/CG57  [Accessed 16 December]

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Reference

DermNET NZ (20112)Topical steroids. Available at: http://www.dermnetnz.org/treatments/topical-steroids.html  [Accessed 16 December 2011]

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Reference

Fitzmaurice S, Pugashetti R, Gattu S (2008) Occlusion strategy in topical therapy – a review. US Dermatology; 36-38.

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