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Steroid ladder for eczema

Dr Karen Martin
Reviewed by Dr Karen MartinReviewed on 19.10.2023 | 7 minutes read

Healthcare professionals use a steroid ladder for prescribing topical creams to patients, often starting with the mildest possible steroid before moving on to the next one up the ladder.

Steroid creams, also known as topical corticosteroids, work by exerting anti-inflammatory and immunosuppressive effects on the skin. The active ingredients in these creams are synthetic versions of corticosteroids, which are hormones naturally produced by the adrenal glands.

How do steroid creams work?

The primary mechanism of action involves the modulation of various cellular processes in the skin to reduce inflammation and alleviate symptoms associated with certain skin conditions. Here's a breakdown of how steroid creams work:


Steroids inhibit the inflammatory response in the skin. Inflammation is a complex process involving the release of various chemical mediators, such as prostaglandins and cytokines, which contribute to redness, swelling, and itching.

Corticosteroids interfere with the production of these inflammatory mediators, leading to a reduction in the inflammatory response. This helps to alleviate the symptoms of skin conditions like eczema, psoriasis, and dermatitis.

Immunosuppressive effects

Corticosteroids have immunosuppressive properties, meaning they suppress the activity of the immune system. In the context of skin conditions, this is beneficial because many skin disorders involve an abnormal immune response.

By dampening the immune response locally, steroid creams help control the excessive immune activity responsible for inflammation and tissue damage in certain skin conditions.

Inhibition of immune cells

Corticosteroids act on various immune cells, particularly T lymphocytes, which play a key role in the inflammatory process. They inhibit the activation and function of these immune cells, reducing their ability to produce inflammatory substances.

This inhibition helps break the cycle of inflammation and prevents further damage to the skin.

How steroid creams are applied

Steroid creams are usually applied topically to the affected skin areas. The cream or ointment is spread thinly and evenly over the affected area. The frequency of application and the duration of treatment depend on the specific medication, the severity of the condition, and the guidance of the prescribing healthcare professional. It's important to follow the prescribed regimen and not to use more than recommended, as excessive use can lead to side effects.

Important considerations

Steroid creams are generally effective, but their use requires caution. Prolonged or inappropriate use can lead to side effects, including skin atrophy (thinning), striae (stretch marks), and telangiectasia (dilated blood vessels). Stronger formulations are typically reserved for more severe conditions and are often used for shorter durations under close medical supervision. Steroid creams should not be used on the face for extended periods, especially around the eyes, as the skin in these areas is more sensitive.

Doctor’s advice

Mild and moderate steroids

Mild Steroids: Hydrocortisone 1% is classified as a mild topical corticosteroid and is available over the counter in the US. It is commonly used for mild inflammatory skin conditions, such as mild eczema or dermatitis. Patients can self-administer this cream, making it easily accessible for initial symptom relief. However, it's crucial to follow usage instructions and not use it on the face or any sensitive area, as mentioned, to avoid potential complications.

Moderate Steroid: Moving up the ladder, fluocinonide is an example of a moderate-strength steroid. It is often prescribed for moderate eczema or dermatitis where stronger treatment is required. Like hydrocortisone, it should not be applied to the face or any sensitive area. While available without a prescription, it's recommended to use this under the guidance of a healthcare professional for proper management.

Mild and moderate steroids are suitable for initially managing eczema symptoms, particularly when the inflammation is mild to moderate. They can be employed when the affected areas are limited and not responding adequately to non-steroidal treatments like emollients.

If symptoms persist or worsen despite the use of mild or moderate steroids, it's essential to consult a healthcare professional. They may reassess the condition and decide whether a stronger steroid or an alternative treatment is necessary. Additionally, if there are concerns about the appropriateness of continued steroid use or potential side effects, seeking medical advice is crucial.

Potent steroids

Potent Steroid: Betamethasone dipropionate is an example of a potent topical corticosteroid. These are stronger than moderate steroids and are generally available only by prescription. They are used in cases of more severe eczema or dermatitis where the inflammation is intense. However, caution must be exercised, as potent steroids can lead to side effects, and they should not be used on certain sensitive areas like the face, eyelids, groin, armpits, genitals, or in children without expert opinion. Potent steroids are employed when eczema is severe, widespread, or not responding adequately to mild or moderate treatments. They are generally reserved for cases where the benefits outweigh the risks due to their higher potency.

If symptoms do not improve with the use of mild or moderate steroids or if they worsen, it's crucial to seek medical attention promptly. A doctor may reassess the condition, consider the appropriateness of potent steroids, or explore alternative treatments. Additionally, if side effects such as skin thinning or changes in pigmentation are observed, medical advice should be sought for further evaluation.

Very potent steroids

Very Potent Steroid: Clobetasol propionate represents the top of the steroid ladder, classified as a very potent topical corticosteroid. These are the strongest prescription-strength steroids and are reserved for severe cases of eczema or dermatitis where other treatments have proven insufficient. Like potent steroids, they should not be used on specific areas or in children without expert opinion. Very potent steroids are utilized when eczema is severe and in extreme cases, is widespread, and has not responded to milder treatments. Due to their strength, they are generally employed for a short duration under close medical supervision.

Very potent steroids are prescription-only medications.

Given their strength, very potent steroids are usually reserved for situations where the benefits clearly outweigh the risks. Regular follow-ups with a healthcare professional are essential to monitor progress, address any potential side effects promptly, and explore long-term management strategies. If there are concerns about the appropriateness of continued use or if side effects arise, seeking medical advice is crucial.

The stronger options

It's important to note that within the US, the ladder typically progresses from mild to moderate, potent, and very potent steroids. However, there are variations in strength and formulations, and healthcare professionals may consider other options based on individual patient needs. Additionally, there are newer classes of topical treatments, including calcineurin inhibitors like tacrolimus and pimecrolimus, which may be considered in certain situations, especially when steroid use is limited by side effects or other concerns. They are only ever initiated by a specialist and require regular check-ups and blood tests.


Tacrolimus is a calcineurin inhibitor, a class of medications known as topical immunomodulators. Unlike corticosteroids, calcineurin inhibitors work by suppressing the immune response in the skin, specifically inhibiting T-cell activation and the release of inflammatory mediators. Tacrolimus is available in ointment form and is often prescribed for certain inflammatory skin conditions. Tacrolimus is typically prescribed for eczema (atopic dermatitis) in situations where the use of topical corticosteroids may be limited due to concerns about side effects or for areas where corticosteroids might be less effective, such as on the face or around the eyes. It is especially useful in cases where prolonged use of steroids may be problematic, such as in delicate skin areas.

Tacrolimus is a prescription-only medication.

Regular follow-ups with a healthcare professional are recommended when using tacrolimus. If there is a lack of improvement or worsening of symptoms, it's important to consult with a doctor to reassess the treatment plan. Additionally, healthcare providers monitor for potential side effects, including skin burning or itching at the application site, and address any concerns promptly.


Similar to tacrolimus, pimecrolimus is a topical calcineurin inhibitor with immunomodulatory properties. It is available in cream form and is used for the treatment of mild to moderate atopic dermatitis (eczema). Pimecrolimus is often considered when treating sensitive areas of the skin, such as the face or neck, where the use of corticosteroids may be more challenging. It is particularly suitable for individuals who prefer a cream formulation over an ointment.

Pimecrolimus is a prescription-only medication. As with tacrolimus, it requires supervision by a healthcare professional.

Regular monitoring and follow-ups with a healthcare professional are essential when using pimecrolimus. If there is insufficient improvement or if adverse effects occur, consultation with a doctor is necessary to reassess the treatment plan. Pimecrolimus is generally well-tolerated, but like any medication, it's important to be vigilant for potential side effects and address them promptly.

Calcineurin inhibitors like tacrolimus and pimecrolimus offer an alternative to corticosteroids in the treatment of eczema. They are particularly useful in situations where prolonged use of steroids may be a concern, such as on the face or in delicate skin areas. These medications work by modulating the immune response locally, providing anti-inflammatory effects without the potential side effects associated with long-term corticosteroid use, such as skin thinning.

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Dr Karen Martin
Reviewed by Dr Karen Martin
Reviewed on 19.10.2023
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