There may be delayed healing of wounds, particularly when the preparation is used on varicose ulcers. Various infections, such as tinea, herpes and thrush, will be aggravated and the underlying disorder may become masked. Allergies may occur to the preservative, stabilizer or perfume in the preparation. If an antibiotic is also contained in it, this is again more likely to cause allergy problems.

The use of these preparations for facial acne may aggravate the acne, and cause secondary infections as well. Increased facial hair and depigmentation of the skin may also result. Furthermore, if the preparations are used in or too close to the eye, glaucoma, cataract, or activation of corneal herpes simplex may result.

Although theoretically possible, it is extremely rare for topical preparations to be sufficiently absorbed in large enough amounts to have any significant internal side-effect. The only possible exception is when excessive amounts of strong preparations are used over large areas of a child’s skin for long periods. For most adult patients, who use less than 30 grams of potent corticosteroid a day on less than one-third of the body, there is little evidence of significant internal side-effects (even with plastic occlusion — which increases, absorption tenfold—overnight). Furthermore the only known side-effect, that of diminishing the body’s own corticosteroid production, is completely reversible within two to three days, should it occur.

The likelihood of internal side-effects may be diminished by the appropriate choice of the weakest effective preparation. Similarly, only small amounts of the chosen preparation should be used, and then only when and where necessary. The extent of the area of skin treated is most important, particularly with babies. Occlusive dressings to enhance absorption in thick areas of the skin should not be used over large areas for long periods of time.

Local side-effects may be prevented by using the appropriate strength preparation for as short a period as possible. Small quantities of a preparation are often sufficient besides being more economical, and it is useful to be shown the correct amount to use. For example, a matchhead amount will adequately cover the back of the hand. It is also inadvisable to use these preparations more than twice or possibly three times a day, because of the tendency of the skin to become resistant to then-use as well as the possibility of over-use.

Once the condition is under control, a less potent preparation should be used for maintenance. Where possible, the use of alternative compounds (for example, tar preparations with eczema or dithranol with psoriasis) should replace, or alternate with, that of the corticosteroids. Once the condition has healed, then treatment should be gradually tapered off, to avoid a rebound.

Let me emphasize, however, that although we should be aware of the possible complications of using corticosteroids, this should not deter us from their use. Under careful supervision it is possible to use small quantities of potent preparations for short periods in complete safety, even on the face and creases. Many patients have benefited enormously from their use, and there is no real justification for being left with an uncomfortable, unsightly yet treatable condition because of unwarranted fears of side-effects.

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