Dermatologists' Knowledge of and Preferences Regarding Topical Steroids

July 2013 | Volume 12 | Issue 7 | Original Article | 786 | Copyright © July 2013

Laura F. Sandoval DO,a Scott A. Davis MA,a and Steven R. Feldman MD PhDa,b,c

aCenter for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC
bDepartment of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC
cPublic Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC

BACKGROUND: Topical corticosteroids are the standard-of-care treatment for dermatitis, mild psoriasis, and other inflammatory skin diseases. Prescribing practices rely on knowledge of topical corticosteroid potency, as well as potential side effects including steroid allergies.
PURPOSE: The primary aim of this study is to determine how dermatologists classify particular topical corticosteroids according to potency, and which products they prefer in cases when allergenicity is a concern.
METHODS: The data were collected and analyzed from 105 US-based dermatologists surveyed at the 2011 Summer American Academy of Dermatology meeting.
RESULTS: The majority of dermatologists were in agreement on the potency ranking of many commonly prescribed topical corticosteroids. Two thirds of the surveyed dermatologists expressed concern about allergy to topical corticosteroids. In cases of a suspected allergy, desoximetasone was the leading product dermatologists would choose to prescribe.
LIMITATIONS: The survey was limited to attendees of an educational conference, possibly leading to an overestimation of dermatologist knowledge of topical steroids.
CONCLUSIONS: This study shows that dermatologists are generally knowledgeable about group classifications of corticosteroids in terms of potency and that they can appropriately select a topical product with low potential for allergy.

J Drugs Dermatol. 2013;12(7):786-789.


Topical corticosteroids are widely prescribed by dermatologists and primary care providers for both acute and chronic inflammatory skin diseases. Topical steroids are prescribed at 21% of office visits to dermatologists.1 With over 24 approved topical steroids available in the US,2 knowledge of the differences in potencies and formulations is key to proper prescribing patterns. Strength or potency is classified by groups I-VII, with group I being superpotent and group VII being low potency, and is based on the vasoconstrictive properties of the steroid molecule which have been established through vasoconstrictor assays.3 Most other countries outside the US use a narrower categorization of class I-IV, with class IV being very potent and class I mild. Available formulations include creams, ointments, lotions, gels, solutions, and foams, greatly expanding the number of options to choose from in this drug class. An understanding of these different formulations is significant since the vehicle influences the rate of absorption, patient preferences, and therefore the efficacy of the medication.4,5 Severity of disease, extent of lesions, location being treated, duration of treatment, and age of patient must all be considered in choosing an appropriate topical corticosteroid.4,6
Disadvantages of topical steroids include atrophy, striae, telangiectasias, acne, and rosacea.6 Systemic absorption leading to adrenal suppression and Cushing syndrome may occur.7 Additionally, contact dermatitis can result from an allergy to ingredients found in the topical steroid vehicle or to the steroid molecule itself. Potential allergens include ingredients and preservatives commonly used in vehicles, especially creams.8 Solutions and ointments tend to be the least allergenic. Allergies to corticosteroid molecules themselves has gained recognition, with a reported prevalence that varies between 0.5-5%.9-11 While the potential of having an allergy to any corticosteroid exist, as well as the possibility for cross-reactivity, tixocortol pivalate, not commercially available in the US, budesonide, and hydrocortisone 17-butyrate are the most common culprits.11-13 Tixocortol pivalate, used as a stand-in for hydrocortisone, and budesonide are now routinely screened for in patch test panels.12 A thorough knowledge of topical corticosteroids and their potential adverse effects, including the possibility for a contact allergy, is key to recognizing and preventing occurrences.
While topical steroid prescribing patterns by dermatologists have been studied, the foundation upon which these physicians choose a specific steroid based on their knowledge of this drug class has not been fully characterized.1 This study aims to assess dermatologists’ knowledge of topical corticosteroids potency, and which products they prefer in cases of suspected steroid or vehicle allergenicity.