Topical corticosteroids are effective in helping to heal cracked and broken eczematous skin. While these creams and ointments are more easily absorbed through eczematous skin, they are safe as long as they are used according to the advice of your physician and their use is tapered or dis- continued when the skin is healed. If your skin is tender and swollen it may be infected; this should be evaluated by your doctor.
Babies and very young children are at risk of absorbing topically applied corticosteroids into the bloodstream, especially when these medications are very potent, applied in large quantities too frequently, used for prolonged periods of time, or used inappropriately under a diaper or other cov- ered (occluded) area. Thus, when topical steroids are used improperly, there may be a risk of slowing of growth (height). Corticosteroids taken by mouth also are absorbed into the bloodstream. These can reduce the body’s production of natural corticosteroids, weaken immune responses and affect growth, but do not affect brain development. Topically applied corticosteroids used in the appropriate quantity and for the appropriate du- ration are unlikely to affect growth or the body’s ability to fight infections.
It is important to follow the advice of your doctor when using topical corticosteroids in babies and young infants.
When making a decision about the need for topical corticosteroid therapy, it is critical to weigh the potential risks of the treatment against the risks of the disease. Untreated eczema can have an enormously negative impact on overall well-being, restful sleep, ability to concentrate and learn, and family dynamics, which can, in turn, impair a child’s normal growth and development. When topical corticosteroids are applied correctly, the risks of the disease are far greater than the risks of treatment.
Topical corticosteroids rarely cause skin discoloration, which resolves when the treatment is stopped. Skin discoloration is much more likely to result from the eczema itself, because skin inflammation can increase or decrease the amount of tan pigment in the skin. Skin discoloration from eczema will typically resolve over time, but may take several months. That being said, some pigmentation changes can be permanent if the in- flammation is severe and lasts for a long time. Once the hyperpigmentation affects the dermal layer, it is very difficult to resolve.
If topical corticosteroids are used for long periods, they can occasionally cause a temporary, mild increase in fine hair growth in the treated areas, although this is rare. Frequent scratching can also cause a temporary, mild increase in fine hair growth.
There is no evidence that topical corticosteroids prolong the natural course of the disease. The appearance of worsening or prolonged eczema can be an allergic reaction to the steroid or formulation. Any worsening (or failure to improve) should be evaluated for allergic contact dermatitis.
Proper bathing and moisturizing is essential in managing chronic eczema. Although moisturizers are a first-line treatment, when used alone they will only control the very mildest forms of eczema. Moderate or severe eczema generally cannot be treated effectively with moisturizers alone. Once the skin becomes red (inflamed), additional anti-inflammatory medication is needed to control the disease. Anti-inflammatory treatments include topical corticosteroids, topical calcineurin inhibitors (TCIs such as Elidel or Protopic), ultraviolet light therapy, or systemic medications.
It is true that only a thin layer is needed, but it is important to apply enough to cover all the red areas. A useful way of knowing the correct amount to apply is the fingertip rule: Squeeze a ribbon of the topical corticosteroid onto the tip of an adult index finger, between the fingertip and the first finger crease. This amount of corticosteroid represents “one fingertip unit” and should be enough to cover an area of skin the size of two flat adult palms of the hand (including fingers).