Navigating Appropriate Use of Topical Corticosteroids in Atopic Dermatitis Treatment

EP: 1.Recognizing Atopic Dermatitis in Practice and Differentiating From Other Skin Conditions

EP: 2.Differences in Atopic Dermatitis Presentation Across Age Groups and Skin Types

EP: 3.Methods for Determining Atopic Dermatitis Severity in Clinical Practice

EP: 4.Addressing Current Topical Management of Atopic Dermatitis in Primary Care

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EP: 5.Navigating Appropriate Use of Topical Corticosteroids in Atopic Dermatitis Treatment

EP: 6.Addressing Risks and Adverse Effects of Long-Term Topical Corticosteroid Use

EP: 7.Exploring Newer Nonsteroidal Topical Treatments for Atopic Dermatitis: PDE4 Inhibitors

EP: 8.Exploring Newer Nonsteroidal Topical Treatments for Atopic Dermatitis: JAK Inhibitors and AhR Agonists

EP: 9.Closing Thoughts With Patient Cases: Choosing the Right Topical Treatment for Patients With Atopic Dermatitis

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Topical Steroids and Calcineurin Inhibitors Discussion

Topical Steroids Overview

Topical steroids were introduced in the 1950s and are categorized by potency (low, medium, high). Carolyn Stolte, CRNP, recommends physicians become familiar with one from each category, specifically naming hydrocortisone (low), triamcinolone (medium), and clobetasol/fluocinonide (high). Long-term daily use causes significant adverse effects including irreversible skin atrophy, striae, rosacea, acne, telangiectasias, purpura, hirsutism, infections, and ocular toxicity. She emphasizes using standardized prescription instructions with built-in breaks (eg, “twice daily for 2 weeks, take a break on the third week”) and prescribing appropriate quantities rather than large amounts with multiple refills to prevent misuse and sharing.

Topical Calcineurin Inhibitors

Tacrolimus and pimecrolimus were introduced in the early 2000s and are popular nonsteroid alternatives among primary care physicians. The most common adverse effect is burning, which can be mitigated by refrigerating the medication before application and reassuring patients the sensation diminishes over time. These medications carry a black box warning (based on systemic calcineurin inhibitor studies) that physicians should discuss with patients, particularly when prescribing for children.

Steroid Selection Guidelines

Carolyn Stolte, CRNP, provides specific guidance for selecting appropriate potency based on location and severity:

• Mild disease, facial application, skin folds, or infants: low potency (hydrocortisone)
• Moderate disease or trunk/limb application: medium potency (triamcinolone)
• Severe or lichenified disease (hands, feet, elbows, knees): high potency

Treatment duration recommendations:

• Mild flares: 5 to 7 days, then break
• Moderate flares: 1 to 2 weeks, then break
• Severe flares: 2-plus weeks with high potency, followed by breaks and eventual tapering

Fingertip Unit Dosing Guide

One fingertip unit is the amount of cream/ointment squeezed from a tube onto an adult’s index fingertip, approximately 0.5 g, covering 2 adult handprints. Carolyn Stolte, CRNP, illustrates with a case example: A 3-year-old with bilateral antecubital fossae dermatitis (each fossa = 1 handprint) would need 1 g per application, 2 g per day (with twice-a-day application), totaling 28 g for a 2-week treatment course. This calculation helps physicians prescribe appropriate quantities rather than excessive amounts.