Your eczema has flared up, and despite keeping your skin clean and moisturized, and avoiding the irritants that can trigger the red, itchy and painful skin symptoms of the condition, you can’t find any relief. What’s next?

One option your doctor may recommend is to apply a topical corticosteroid, also known as a steroid, to ease redness, itchiness, and inflammation so your skin can begin to heal. “Topical steroids are the first line of treatment after you’ve addressed proper skin care using moisturizers, taking warm baths, avoiding irritants and triggers for a flare-up, and treating infections,” says Luz Fonacier, MD, an allergist at Winthrop-University Hospital, part of the Stony Brook University School of Medicine in Mineola, New York, and president of the American College of Allergy, Asthma, and Immunology. “If, in spite of these actions, you still have eczema, then we move into low-potency topical steroids.”

What Steroids Are

Corticosteroids are synthetic drugs that closely resemble cortisol, a naturally occurring hormone that is released in response to stress and infection, and that helps regulate blood pressure and blood sugar. As the Cleveland Clinic explains, corticosteroids work by reducing both inflammation and immune system activity. Some of them are formulated to work topically, or on the surface of the skin. They are not related to illegal and unsafe anabolic steroids, which some athletes use to enhance their performance.

How Using Topical Steroids Can Help Relieve Eczema

Eczema, known more formally as atopic dermatitis, is not one specific condition, but a group of inflammatory skin conditions that can produce rash-like symptoms, lesions, scaly or leathery patches of skin, swelling, soreness and dry itchiness on various parts of the body. It can appear on the face, hands, feet, wrists, ankles, insides of the elbows, behind the knees, sides of the neck, and around the mouth and other areas of the body.

Scientists haven't identified any specific cause of eczema, but people with the condition tend to have an over-reactive immune system that produces inflammation as a result of an irritant or trigger, according to the National Eczema Foundation (NEA). Common irritants include household products, fragrances, metals, and certain fabrics, such as wool or polyester.

Other triggers of eczema include stress and letting your skin get too dry. For instance, frequent hand-washing in an attempt to help avoid COVID-19 infection can dry out skin and spur flareups, says the NEA. People with seasonal allergies or asthma also tend to be at a higher risk of eczema. So are women and Black Americans, according to the Cleveland Clinic. It usually begins in childhood, but nearly half of children with eczema will outgrow it or have greatly reduced symptoms by the time they reach puberty.

Topical steroids can help reduce the inflammation that's causing your eczema symptoms. The drugs are classified by strength on a scale of 1 to 7, with 1 being the strongest and 7 being the weakest. Clobetasol propionate 0.05 percent (Clobex) (Clobex) lotion, spray, or shampoo is an example of a class 1 “super-potent” topical steroid. Cortaid and other over-the-counter hydrocortisone creams and ointments belong to class 7, which is “least potent.” The NEA offers a detailed rundown on the classes of various medication and steroids for eczema, and the National Psoriasis Foundation has a potency chart for dozens of topical steroids, divided by class.

How to Know When to Use Topical Steroids and at What Strength

If a low-potency topical steroid doesn’t work for you, your doctor may prescribe a stronger one for you to apply, says Dr. Fonacier. A nonsteroidal topical medication, such as crisaborole or tacrolimus, may be added to your treatment as well.

“If that’s not working, then you go onto other systemic treatments for eczema,” she explains. “They include phototherapy, Dupilumab, which is an injectable, and then systemic immunosuppressants — which are not FDA-approved for severe atopic dermatitis, but we know they work — like cyclosporine and methotrexate. You may even try oral steroids, but then you’re talking about complications.” The steps she outlines belong to a protocol called the Atopic Dermatitis Yardstick, depicted in a chart from a paper published January 2018 in the journal Annals of Allergy, Asthma and Immunology, which Fonacier coauthored.

Peter Lio, MD, dermatologist at Northwestern University’s Feinberg School of Medicine in Chicago and a member of the board of directors of the NEA, takes an alternate approach to deciding when to prescribe topical steroids and at what strength. He integrates alternative medicine techniques into his practice and research, such as the use of probiotics, plant-based treatments such as sunflower seed oil, and an emphasis on nutrition. “The goal is to try to use as little medication as possible, for as short a period of time as possible, to get people comfortable and to get the eczema under control,” he explains. “However, if it’s more than a mild disease, all of my tricks outside of the conventional medication often are not enough.”

In these cases, he says, the goal is to minimize drug exposure over the long term, which can mean using a higher class of topical steroid for a shorter period of time than would be needed with one of a lower potency. “We probably do more damage to the skin by using even a mild steroid for a long period of time than we do by using a more powerful one to nip it in the bud and then be done with it,” Dr. Lio explains.

Side Effects and Complications of Topical Steroid Use

A variety of complications may arise from topical steroid use or overuse. That’s why the NEA says the medications should not be used continuously for more than two to four weeks, particularly when using particularly when they are of “high potency.”

Skin Appearance Changes

Among the side effects are skin that becomes thinner (atrophy), thicker (lichenification), darkened, or lightened on the site where the medication has been applied. Stretch marks (striae) and small broken blood vessels (telangiectasias) can develop as well. “In skin that’s rapidly expanding in, for instance, teenagers who are rapidly growing in their legs and arms; or a breastfeeding woman whose skin is rapidly contracting and expanding all day to accommodate the breast milk — all of these areas are higher risk for developing striae,” says Jenny Murase, MD, a dermatologist at the Palo Alto Medical Foundation in Mountain View, California, who advises caution with potent topical steroids to help prevent such complications. “Use the topical judiciously in areas where there’s an expansion of skin, or in the armpits and the groin.”

The NEA warns that overusing moderate-to-high potency topical steroids and then abruptly stopping usage can lead to “topical steroid withdrawal syndrome,” which can result in burning, stinging, swelling, skin sensitivity, pimple-like bumps and pustules, as well as bright red skin in individuals with light complexions. Research shows such symptoms are associated most with using such topical steroids daily for more than a year, and appear within days to weeks of stopping.

An Increased Risk for Certain Health Conditions

There are also possible systemic side effects of topical steroids, particularly with long-term use, adds Fonacier, supporting previous research. “If you’re putting them on so often, there’s a possibility of absorption, especially with children.” Systemic side effects, which can be similar to those caused by oral steroid medication, include cataracts, glaucoma, osteoporosis, neuropsychiatric effects, muscle weakness, and diabetes, as well.

In August 2019, the Journal of Dermatological Treatment published an analysis of four observational studies performed between 2006 and 2019, which found a “significant association” between topical steroid use and higher risk of developing type 2 diabetes, regardless of the potency of the medication being used. The more an individual’s dose increased and the longer they took the medication, the stronger the association with diabetes. As the study authors noted, systemic steroid use (taken by mouth or injection) is known to be associated with insulin resistance. But more research is needed to establish whether there’s a causal relationship between steroids applied on the skin and developing type 2 diabetes.

Why You Should Try to Avoid ‘Steroid Phobia’

It’s important to understand potential side effects, especially with overuse. Yet don’t let fear of side effects prevent you taking advantage of topical steroids, says Lio, a sentiment that Fonacier echoes. “One of the reasons that eczema is poorly treated is steroid phobia,” mostly driven by fear of complications, explains Fonacier. To avoid or minimize complications, particularly with long-term use of topical steroids, simply make sure you are being monitored by a medical professional who can identify any problems before they worsen. Be sure to let your doctor know of any concerns so they can be addressed promptly and effectively.

Finally, if your symptoms persist or onerous side effects develop, says Fonacier, know when it’s time to move on and ask your doctor to look at other treatment options.

Do You Need a Topical Steroid to Help Control Eczema?