How are topical corticosteroids classified?

Topical corticosteroids are classified according to their potency, usually as low, medium, high or very-high potency, which influences therapeutic choice and the risk of adverse effects.

How should the potency of a topical corticosteroid be selected?

Potency should be selected according to the dermatosis, severity, anatomical site, patient age, skin thickness, extent of the affected area and expected duration of treatment.

Which corticosteroids should be used on the face and skin folds?

On the face, skin folds and genital area, low-potency corticosteroids should be preferred and used for short periods because of the higher risk of atrophy, telangiectasia, perioral dermatitis and other local adverse effects.

When should high-potency corticosteroids be used?

High-potency corticosteroids may be used in thick, lichenified inflammatory dermatoses or lesions located on thicker skin, such as palms, soles, scalp or psoriatic plaques, for limited periods.

What are the main local adverse effects?

The main adverse effects include skin atrophy, striae, telangiectasia, purpura, hypopigmentation, perioral dermatitis, acneiform eruption, induced rosacea, hypertrichosis and increased susceptibility to skin infections.

Can topical corticosteroids cause systemic effects?

Yes, although this is uncommon. The risk increases with potent corticosteroids, extensive application, prolonged use, occlusion, damaged skin and in children, with possible suppression of the hypothalamic-pituitary-adrenal axis.

What precautions are needed in children?

In children, the lowest effective potency should be used for short periods, avoiding extensive application, unnecessary occlusion and potent corticosteroids on sensitive areas because of greater relative systemic absorption.

How can the risk of adverse effects be reduced?

The risk is reduced by choosing the lowest effective potency, limiting duration, avoiding prolonged continuous use, adapting treatment to the anatomical site, reviewing the diagnosis if there is no response and ensuring clinical follow-up.

Topical corticosteroids: potency classes, formulations and clinical precautions

Topical corticosteroids are one of the main therapeutic classes in dermatology and are widely used in the treatment of inflammatory dermatoses. Their efficacy and safety depend not only on the active substance and concentration, but also on potency class, galenic formulation, treated area and treatment duration. Inappropriate selection may result in therapeutic failure or relevant adverse effects, particularly on the face, skin folds, periocular area and in paediatric patients.
This table summarises the main topical corticosteroids by potency class, available formulations and essential clinical precautions, including situations in which their use should be avoided, common adverse reactions and practical criteria for vehicle selection. The aim is to support safer, more rational prescribing adapted to the clinical context, always favouring the lowest effective potency and periodic reassessment.

Podcast transcript

General principles

Topical corticosteroids are widely used in the treatment of inflammatory dermatoses. Their efficacy and safety depend decisively on the potency class, galenic formulation, application area and duration of treatment. Classification by potency class guides therapeutic choice, but it is important to emphasise that clinical potency does not depend only on the drug and concentration, being also influenced by the vehicle, skin integrity, presence of occlusion and extent of the treated area.

Very-high-potency corticosteroids

Very-high-potency topical corticosteroids, such as clobetasol propionate 0.05%, should be reserved for severe and resistant inflammatory dermatoses. Their use should be limited to short courses, always with strict clinical reassessment. They are not recommended on the face, skin folds and genital area, or in the presence of untreated skin infection, rosacea, perioral dermatitis, acne vulgaris or ulcerated lesions.

High-potency corticosteroids

High-potency corticosteroids, including betamethasone, mometasone, methylprednisolone and fluticasone in specific formulations, are effective in the treatment of moderate to severe inflammatory dermatoses. They should be used for limited periods, avoiding more than one to two applications daily. Prolonged or inappropriate use is associated with an increased risk of local and systemic adverse effects.

Medium-potency corticosteroids

Medium-potency corticosteroids have a more favourable safety profile and are frequently used in inflammatory dermatoses of intermediate severity or during phases of therapeutic step-down. In these cases, vehicle selection is particularly relevant, allowing treatment to be adapted to lesion type and anatomical site, optimising efficacy while minimising risk.

Low-potency corticosteroids

Low-potency corticosteroids, such as hydrocortisone 1%, are preferred on areas of thin skin, particularly the face, skin folds and genital area, as well as in paediatric patients. They are appropriate for short courses or intermittent maintenance therapy, always with adequate clinical monitoring.

Adverse reactions and safety

Possible adverse reactions include skin atrophy, irreversible striae, telangiectasia, local hypertrichosis, hypopigmentation, as well as corticosteroid-induced acne or folliculitis. Untreated skin infections may worsen and, in specific situations, systemic absorption may occur. Prolonged periocular use is associated with a risk of glaucoma and cataract, and prolonged use of potent corticosteroids on the face or genital area may lead to topical corticosteroid withdrawal syndrome.

Choice of formulation

Appropriate formulation selection is essential. Creams are preferable for moist or exudative lesions, ointments for dry or lichenified lesions, and lotions, solutions or foams for hairy or extensive areas. Occlusion and the combination with keratolytic agents increase corticosteroid penetration and the risk of adverse effects, and should therefore be used with caution.

Principles of rational use

In all cases, priority should be given to the lowest effective potency, the shortest possible duration and regular clinical reassessment, in order to maximise therapeutic benefit and reduce the risk of adverse effects.

Clinical cases

Clinical cases — Topical corticosteroids: potency, formulations and safety

Case 1 — Atopic dermatitis in skin folds, potency choice and safety

A 4-year-old child with atopic dermatitis in flare, with erythema and pruritus in the antecubital and popliteal folds. No signs of infection. The parents ask for a “strong” and rapid treatment. Daily emollient already being used.
What is the most appropriate induction option?

Clobetasol propionate 0.05% ointment for 3 weeks
Low-potency topical corticosteroid, for example hydrocortisone 1%, or medium potency, for a short course, with reassessment
Betamethasone dipropionate 0.05% under overnight occlusion for 2 weeks
Topical clindamycin alone

See answer

b) Low potency, or medium potency depending on severity/site, for a short course. Rationale: In skin folds and in paediatrics, absorption is higher and the risk of atrophy/striae increases. The lowest effective potency should be preferred, for a short period and with reassessment, while maintaining emollient therapy. Very potent corticosteroids and occlusion in children increase the risk of adverse effects.

Case 2 — Thick, dry plaques on the elbows, potency and vehicle

A 48-year-old man with chronic erythematous scaly plaques on the elbows, with thick skin and superficial fissures. He reports poor response to moisturising creams and prefers something “that does not run”. No associated infection.
What is the best initial choice of formulation and potency?

High-potency corticosteroid in ointment, with a more occlusive effect, for a short course, with reassessment
Hydrocortisone 1% cream for 4 weeks
Clobetasol propionate 0.05% cream for continuous use for 2 months
Low-potency aqueous lotion applied under daily occlusion

See answer

a) High potency in ointment for a short course. Rationale: In dry, lichenified and thick lesions, an ointment is preferable because of its more occlusive effect and greater clinical potency. A high-potency corticosteroid may be appropriate for a short course, avoiding prolonged use and defining a step-down and reassessment plan.

Case 3 — Recurrent facial erythema after a “strong cream”, situation to avoid

A 32-year-old woman with facial erythema and burning for several months, with scattered papules and worsening after stopping a “strong corticosteroid” used daily “for redness”. She reports improvement while applying it and worsening when it is stopped. No fever. No relevant comorbidities.
What is the most appropriate interpretation and management?

Continue a potent corticosteroid on the face indefinitely
Suspect corticosteroid-induced rosacea/perioral dermatitis and avoid potent corticosteroids on the face; plan tapering and alternative therapy
Start overnight occlusion to reduce inflammation
Add a topical antibiotic and keep the potent corticosteroid as baseline treatment

See answer

b) Corticosteroid-induced rosacea/perioral dermatitis, and possible withdrawal syndrome. Rationale: Prolonged use of potent corticosteroids on the face may induce or worsen rosacea and perioral dermatitis, and cause rebound worsening on discontinuation. Potent corticosteroids on the face should be avoided, gradual tapering should be considered when appropriate, and alternative therapy directed at the diagnosis should be instituted, for example barrier measures and specific treatment for rosacea/perioral dermatitis. Occlusion increases absorption and the risk of adverse effects.

FAQ

Frequently asked questions — Topical corticosteroids

1) What does “potency class” mean in a topical corticosteroid?

The potency class reflects the expected anti-inflammatory strength of the topical corticosteroid, low, medium, high or very high, and guides prescribing. In practice, clinical potency does not depend only on the drug and concentration: it is influenced by the vehicle, with ointments tending to be more occlusive, skin integrity, the treated area and the presence of occlusion, which significantly increases absorption.

2) How should potency be selected safely?

The lowest effective potency and the shortest possible duration should be preferred, with reassessment. In general, low-potency corticosteroids are preferred for the face, skin folds and genital area, as well as in paediatrics. Medium to high potencies may be used on the trunk and limbs according to severity, while very-high-potency agents should be reserved for severe and resistant dermatoses, in short courses.

3) Which areas require greater caution, due to higher risk of adverse effects?

Maximum caution is needed in areas of thin skin, such as the face, skin folds and genital area, and also in the periocular area, where prolonged use may be associated with risk of glaucoma and cataract. In infants, the nappy area may act as occlusion, increasing absorption. In these contexts, prefer low potency and short courses.

4) When should topical corticosteroids be avoided?

They should be avoided in untreated skin infection, bacterial, fungal or viral, in ulcerated or secondarily infected lesions until adequate control is achieved, and in conditions such as rosacea and perioral dermatitis, especially with potent corticosteroids on the face. In urticaria, topical corticosteroids are generally ineffective, as the process is predominantly dermal and systemic.

5) What are the most relevant adverse effects?

Adverse effects include skin atrophy, telangiectasia, irreversible striae, skin fragility and pigmentary changes; corticosteroid-induced acne/folliculitis and worsening of untreated infections may also occur. In specific situations, particularly with potent agents, extensive areas or occlusion, systemic absorption may occur. Prolonged use on the face may induce rosacea/perioral dermatitis and contribute to topical corticosteroid withdrawal syndrome with rebound worsening.

6) How should the vehicle be selected, cream, ointment, lotion, solution or foam?

Vehicle selection should be adapted to the lesion type and site. Creams are useful for moist or exudative lesions; ointments are preferable for dry, lichenified or scaly lesions because of their more occlusive effect; lotions, solutions and foams are useful in hairy areas, for example the scalp, or when extensive areas need to be covered with lower cosmetic “weight”.

7) Is occlusion recommended?

Occlusion can significantly increase penetration and clinical potency, but it also increases the risk of atrophy and systemic absorption. It should be used only when clearly indicated and for short periods, and should be avoided especially in paediatrics and in thin-skin areas. The nappy area may act as unintended occlusion.

8) What is the typical duration and how many applications per day are recommended?

In general, there is no need to exceed one to two applications daily. High and very-high-potency corticosteroids should be used in short courses, with clinical reassessment, avoiding extension without indication. If continued treatment is needed, step-down to a lower potency, intermittent maintenance and reinforcement of adjunctive measures such as emollients should be considered.

References

Authorship and updates

Author(s): Joana Rita Mendes, MD

Last review: (31/12/2025) Filipe Cerca, MD | (31/12/2025) Rita Aguiar, MD

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22/06/2026

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Table of topical corticosteroids organised by potency of action

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Topical corticosteroids: potency classes, formulations and clinical precautions

General principles

Very-high-potency corticosteroids

High-potency corticosteroids

Medium-potency corticosteroids

Low-potency corticosteroids

Adverse reactions and safety

Choice of formulation

Principles of rational use

Clinical cases — Topical corticosteroids: potency, formulations and safety

Case 1 — Atopic dermatitis in skin folds, potency choice and safety

Case 2 — Thick, dry plaques on the elbows, potency and vehicle

Case 3 — Recurrent facial erythema after a “strong cream”, situation to avoid

Frequently asked questions — Topical corticosteroids

1) What does “potency class” mean in a topical corticosteroid?

2) How should potency be selected safely?

3) Which areas require greater caution, due to higher risk of adverse effects?

4) When should topical corticosteroids be avoided?

5) What are the most relevant adverse effects?

6) How should the vehicle be selected, cream, ointment, lotion, solution or foam?

7) Is occlusion recommended?

8) What is the typical duration and how many applications per day are recommended?

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Topical corticosteroids: potency classes, formulations and clinical precautions

General principles

Very-high-potency corticosteroids

High-potency corticosteroids

Medium-potency corticosteroids

Low-potency corticosteroids

Adverse reactions and safety

Choice of formulation

Principles of rational use

Clinical cases — Topical corticosteroids: potency, formulations and safety

Case 1 — Atopic dermatitis in skin folds, potency choice and safety

Case 2 — Thick, dry plaques on the elbows, potency and vehicle

Case 3 — Recurrent facial erythema after a “strong cream”, situation to avoid

Frequently asked questions — Topical corticosteroids

1) What does “potency class” mean in a topical corticosteroid?

2) How should potency be selected safely?

3) Which areas require greater caution, due to higher risk of adverse effects?

4) When should topical corticosteroids be avoided?

5) What are the most relevant adverse effects?

6) How should the vehicle be selected, cream, ointment, lotion, solution or foam?

7) Is occlusion recommended?

8) What is the typical duration and how many applications per day are recommended?

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