Atopic Dermatitis — Topical Steroid Treatment Recommendations — Clinical Pathway: All Settings

Atopic Dermatitis Clinical Pathway — All Settings

Topical Steroid Treatment Recommendations

  • Remind children that general skin care recommendations with at least twice daily emollient use should continue.
  • Apply topical steroids to affected areas twice daily 30-60 minutes before applying emollient to avoid diluting its therapeutic effects.
  • Prescribe an adequate amount of topical steroid ointment (Use ED AD Discharge SmartSet).
  • Systemic steroids are not indicated for AD treatment and can cause flare when discontinued.
    • If needed for other conditions, prescribe enough topical steroid to continue after flare for 14 days.

Topical Steroids Treatment Recommendations by Flare Severity, Skin Location, Child's Age

Severity Location

Age < 3 yrs

Ointment covered by most insurance payers

Age ≥ 3 yrs

Ointment covered by most insurance payers
Mild Face/Genitals 2.5% Hydrocortisone base 2.5% Hydrocortisone base
Mild Body 2.5% Hydrocortisone base 0.025% Triamcinolone acetonide
Moderate Face/Genitals 0.025% Triamcinolone acetonide 0.025% Triamcinolone acetonide
Moderate Body 0.025% Triamcinolone acetonide 0.1% Triamcinolone acetonide
Severe Face/Genitals 0.025% Triamcinolone acetonide 0.025% Triamcinolone acetonide
Severe Body 0.1% Triamcinolone acetonide 0.05% Fluocinonide

Prescribing Topical Steroids, Formulation, Potency

Prescribing Topical Steroids

Potency
  • Use lower potency steroids on less mature, thinner skin to prevent skin atrophy
    • Age < 3 yrs and face or genital area
  • Use higher potency steroids in children > 3 yrs with severe disease
Formulation
  • Ointment
Frequency
  • Twice daily
Duration
  • 2 weeks
Amount to Prescribe
  • Prescribe enough for 2 weeks:
    • Focal area affected: 1-2 tubes 60-80 g at minimum; consider larger amount for larger surface area
    • Diffuse area affected: 120-454 g, depending on child’s size
  • Use ED AD Discharge Smart Set
Tube Size, Grams
  • Hydrocortisone base ointment: 2.5% 20 g, 60 g, 454 g
  • Triamcinolone acetonide ointment: 0.025% 15 g, 80 g, 454 g
  • Triamcinolone acetonide ointment: 0.1% 15 g, 80 g, 454 g
  • Fluocinolone acetonide ointment: 0.05% 15 g, 30 g, 60 g

Topical Steroid Formulations

Ointment is typically the formulation of choice for AD

Ointment
  • More occlusive than other preparations allows for better absorption of topical medication
  • Provides more lubrication but often greasy
  • Typically does not contain preservatives, so it causes less irritation, sting
  • Avoid use on hair-bearing areas
Cream
  • Poor occlusive effects compared to ointment, so less potent than ointments of same concentration
  • Good lubrication improved drying effects compared to other preparations
  • Can be used in exudative areas
  • Less greasy
  • Typically contain preservatives, cause irritation, sting more
    • More risk of allergic reaction
  • Effective in hair-bearing areas
Lotions, Gels
  • Poor occlusive effects compared to other formulations
  • Typically contain alcohol, improves drying effects
  • May cause more irritation, stinging
  • Less greasy
Foams, Solutions, Oils
  • Effective for use in hair-bearing areas
  • Systemic steroids are not indicated for treatment of AD, cause flare when treatment is finished.
  • If they are needed for another condition, prescribe enough topical steroid ointment to continue after the flare for 14 days.

Topical Steroid and Potency

Topical steroids are grouped based on their relative anti-inflammatory activity and are classed 1-7 based on this activity. Class I is the very highest potency and Class 7 the lowest. Potency can vary depending on the vehicle (cream, ointment, solution, gel) with ointment and gels generally stronger than creams.

Common Medications Ordered Formulations Available
(ointment always preferred) 		Potency, Class
  • Hydrocortisone base or acetate 1% and 2.5% (Formulary)
  • Ointment
  • Lowest Class VII
  • Alclometasone dipropionate 0.05%
  • Desonide 0.05%
  • Hydrocortisone base or acetate 2.5%
  • Ointment, cream
  • Cream
  • Cream
  • Low Class VI
  • Desonide 0.05%
  • Hydrocortisone butyrate 0.1%
  • Triamcinolone acetonide 0.025% (Formulary)
  • Ointment
  • Ointment, cream, solution
  • Ointment, cream
  • Lower Medium Class V
  • Clobetasone butyrate 0.05%
  • Fluocinolone acetonide 0.025% (Formulary)
  • Hydrocortisone valerate 0.2%
  • Triamcinolone acetonide 0.1% (Formulary)
  • Ointment, cream
  • Ointment
  • Ointment, cream
  • Ointment, cream
  • Medium Class IV
  • Betamethasone valerate 0.1%
  • Fluticasone propionate 0.005%
  • Ointment, cream
  • Ointment
  • Ointment
  • Higher Medium Class III
  • Betamethasone dipropionate 0.05%
  • Fluocinonide 0.05% (Formulary)
  • Desoximetasone 0.25%
  • Mometasone furoate 0.1%
  • Cream
  • Ointment, cream
  • Ointment, cream
  • Ointment
  • High Class II

Very-High Class I

Do not prescribe. See recommendations for subspecialty referral.