Introduction
This article provides a step-by-step approach to counselling a patient on topical corticosteroids in an OSCE setting.
Opening the consultation
Wash your hands and don PPE if required.
Introduce yourself including your name and role.
Confirm the patient’s name and date of birth.
Explain the reason for the consultation: “Today, I’d like to talk to you about steroid creams and ointments. Would that be okay?”
It is important to establish good rapport and an open line of communication: “If you have any questions at any point, or if something is not clear, please feel free to interrupt and ask me.”
Make sure to check the patient’s understanding at regular intervals throughout the consultation and provide opportunities to ask questions (this is often referred to as ‘chunking and checking’).
Ideas, concerns and expectations
A key component of counselling involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE).
Asking about a patient’s ideas, concerns and expectations can provide insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.
It can sometimes be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided some examples for each of the three areas below.
Ideas
- “Have you heard of topical corticosteroids before?”
- “What do you know about topical corticosteroids?”
- “Do you know the reasons why people may use topical corticosteroids?”
Concerns
- “Do you have any particular worries about using topical corticosteroids?”
Expectations
- “Is there anything in particular you hoped we would cover today relating to topical corticosteroids?”
- “Is there anything in particular you would like me to focus on today?”
Patient history
Although the purpose of this station is to counsel the patient, it is a good idea to gather a quick, focused history early in the consultation.
This should include exploration of the patient’s symptoms and management of their condition, including trials of previous medications and their impact, compliance and adverse effects.
Understanding the patient’s care so far will help you tailor any advice and personalise the information for their specific situation.
Contraindications and cautions
While topical corticosteroids are suitable for most adults and children, they may not be recommended in some situations:1
- Broken or infected skin (e.g. impetigo, cold sores or fungal infections), unless specifically advised by a clinician. The anti-inflammatory and vasoconstrictive effects of corticosteroids can mask signs of infection.1-4 If an infection is present, a topical corticosteroid may be used in combination with an appropriate anti-infective agent.
- Certain skin conditions such as rosacea, acne or perioral dermatitis.1,2
What are topical corticosteroids, and when are they used?
A topical corticosteroid, or topical steroid, is a steroid medicine applied directly to the skin to reduce inflammation.1,2,3,5
Topical corticosteroids are used to treat a range of inflammatory skin conditions, such as eczema, psoriasis, and contact dermatitis, as well as skin conditions with an autoimmune basis, including vitiligo, lichen sclerosus, discoid lupus erythematosus, and alopecia areata.2,4
How do topical corticosteroids work?
Steroids are naturally occurring hormones produced in the body.2,6 They can also be manufactured synthetically and used as medicines taken orally, given by injection or applied to the skin.
Topical corticosteroids act on skin cells and have anti-inflammatory, immunosuppressive, anti-proliferative and vasoconstrictive effects.4,5 These actions help reduce heat, itch and soreness in affected skin.6
They are generally used to relieve symptoms rather than cure the underlying condition.5,6
Example
“Topical corticosteroids are medicines used to reduce inflammation in the skin. They work by calming the immune response and narrowing small blood vessels in the affected area. This helps ease redness, itching and irritation. They are used to control flare-ups and relieve symptoms rather than cure the underlying condition”
Types of topical corticosteroids
Topical corticosteroids are classified by strength.1,7 The appropriate strength is chosen based on the condition being treated, the patient’s age and the area of skin involved.2
Absorption, and therefore potency, is influenced by the thickness of the stratum corneum.7
Stronger corticosteroids are generally used on the body, while milder preparations are preferred for the face, neck and skin folds such as the underarms, breast folds and groin, as these areas absorb topical steroids more readily.3,5 Milder corticosteroids are also recommended for children.
Table 1. Potency of topical steroids
| Strength | Examples |
|
Mild |
|
|
Moderate (2-25 times as potent as hydrocortisone) |
|
|
Potent (100-150 times as potent as hydrocortisone) |
|
|
Very potent (up to 600 times as potent as hydrocortisone) |
|
For more information, see the Geeky Medics guide to the topical steroid ladder.
Formulations
Topical corticosteroids are available in various formulations including creams, ointments, lotions, mousses, shampoos, gels and tapes.2,4
Creams are the most commonly used, while ointments are more suitable for dry, non-hairy skin.5 Ointments contain less water and more oil or paraffin than creams, which means they require fewer preservatives. They are often preferred in more severe disease, though some patients find them less acceptable due to their greasiness.
In the long term, patient preference is more important than the specific formulation, so involving patients in these decisions is essential.
Absorption of a topical corticosteroid is greater when used in an ointment formulation or when applied under occlusion, such as tapes or cling film.7
How to use topical corticosteroids?
Fingertip units
The fingertip unit (FTU) is used to guide how much topical corticosteroid should be applied to a specific area of skin.5
One FTU is the amount of product squeezed from a standard tube along the length of an adult index finger, from the fingertip to the first finger crease.2 One FTU is sufficient to cover an area of skin roughly the size of two adult hands placed together.
The quantity required varies with age, sex and body area:
- Adult male: 1 FTU provides approximately 0.5 g
- Adult female: 1 FTU provides approximately 0.4 g
- Child aged 4 years: around one-third of the adult amount
- Infant aged 6 months to 1 year: around one quarter of the adult amount
The amount of cream used varies with body part.
Table 2. FTUs for different body areas.8
| Area | Fingertip units |
| One hand | 1 FTU |
| One arm | 3 FTU |
| One foot | 2 FTU |
| One leg | 6 FTU |
| Face and neck | 2.5 FTU |
| Trunk, front and back | 14 FTU |
| Entire body | Around 40 FTU |
How to apply topical corticosteroids
Patients should apply the cream in the direction of hair growth, as this reduces build-up at the hair follicle base, which can lead to folliculitis.2 For example, on the arm, apply from the elbow towards the wrist.
Using emollients alongside steroids
Emollients can be used before or after a topical corticosteroid to relieve dryness and irritation.5 Many people are prescribed both treatments together.2,5
They can be used at the same time of day, but patients should be advised to leave a 30-minute gap between applications to avoid diluting the corticosteroid or spreading it to areas that do not require treatment.
Choice of strength and treatment areas
Potent preparations are usually reserved for short-term use, while weaker ones are used for maintenance.7 More than one topical corticosteroid may be prescribed for different areas of the body.
Patients should be clear which preparation to use on each area. If unsure, they should speak to a pharmacist or contact a doctor.
How often and how long to use treatment
Topical corticosteroids are typically applied once daily to inflamed skin, ideally after a shower.6
Treatment duration varies with age, the condition being treated, and the body area involved.6 Courses may last a few days or extend to several weeks.1,5
Treatment may then be stopped, reduced in frequency or stepped down to a less potent preparation. Continuing for a couple of extra days can help reduce rebound flares.6
In some cases, such as severe eczema, long-term intermittent use known as ‘weekend therapy’ may be advised to prevent ongoing flare cycles while minimising overall steroid exposure.
Example
“Always wash your hands before applying a topical corticosteroid. Squeeze the topical corticosteroid in a line from the last finger crease to the tip of the fingertip. This is one fingertip unit (FTU).”
“One FTU is sufficient to treat an area equivalent to two adult handprints. Apply the topical corticosteroid in the direction of hair growth. Do not rub it in as this can cause build-up on the hair follicles and cause an infection.”
“Remember to always wash your hands after applying a topical corticosteroid. It is important that corticosteroids are not used more frequently or for longer periods than advised as this may increase the risk of side effects to the skin. On the other hand, not using enough can limit how well the corticosteroid will work, and increase the risk of it needed to be using in the long-term.”
Steroid monitoring
Patients should be monitored to assess the effectiveness of the treatment.4 Unsupervised use of topical corticosteroids increases the risk of local and systemic side effects, and treatment should usually not continue for longer than 2 to 4 weeks, regardless of potency.
If a topical corticosteroid causes irritation, seek advice from the medical or nursing team overseeing the treatment.3
Side effects
If used appropriately under medical supervision, side effects from topical corticosteroids are uncommon.2,5
The risk depends on the potency of the corticosteroid, duration of treatment, the area of skin treated and the underlying skin condition.7 When used short-term and applied only to affected skin, the risk of side effects is low.6
Local side effects
A short-lived stinging or burning sensation is the most common effect when treatment is first applied, and usually improves as the skin adapts or inflammation settles.1,2
Local cutaneous side effects are more likely with potent corticosteroids used daily for long periods (e.g. several months).5
Possible local side effects include:1,4,5,7
- Skin thinning (atrophy)
- Stretch marks (striae), particularly in thinner skin areas such as the groin or armpits
- Easy bruising and increased skin fragility
- Enlarged superficial blood vessels (telangiectasia)
- Folliculitis
- Secondary infection or masking of existing infections such as impetigo, tinea or herpes simplex
- Localised increase in hair growth (hypertrichosis)
- Contact dermatitis
- Perioral dermatitis
- Steroid rosacea
- Acne
- Hypopigmentation
- Delayed wound healing
- Cataracts or glaucoma when applied near the eyes
Systemic side effects
Systemic effects are rare because only small amounts of corticosteroid are absorbed through the skin, but they can occur with prolonged use of highly potent products over large areas, especially on thinner skin.1,4
High-potency corticosteroids should not be used for longer than two weeks to reduce this risk.
Possible systemic side effects include:
- Glaucoma
- Suppression of the hypothalamic-pituitary axis
- Adrenal suppression, particularly when potent products are used regularly (e.g. more than 50 g per week). Estimating tube use over time can help assess this risk and guide weaning
- Cushing syndrome
- Hypertension
- Hyperglycaemia
Topical steroid withdrawal
Continuous use of potent topical corticosteroids over long periods, often more than 12 months, can lead to a withdrawal reaction when treatment is stopped.1,6
This is known as topical steroid withdrawal (TSW), a rare rebound phenomenon following chronic overuse.9 Management focuses on stopping the corticosteroid and providing supportive care such as emollients, cold compresses, analgesia and psychological support.
Symptoms of TSW may include:
- Redness, which may appear darker or grey in more pigmented skin. The ‘red sleeve sign’ describes circumferential erythema affecting the limbs
- Burning, stinging, itching or peeling
- Oozing or open sores
- Rebound flare of the treated skin condition, often worse than the initial presentation
- Papules, pustules or nodules
- Shedding of the skin (desquamation)
Complications of TSW may include:
- Sleep disturbance
- Secondary infection
- Psychological distress including anxiety, depression or suicidal ideation
- Fear of using steroids in future treatments
- Flare of the original skin disorder
Example
“When used correctly, topical corticosteroids are generally safe and side effects are uncommon. Most people notice a brief stinging or burning sensation when they first apply the treatment, but this usually settles as the skin improves.”
“Stronger steroids used for long periods can cause changes in the skin such as thinning, stretch marks or increased fragility. This is why it is important to use the preparation exactly as advised and only on the areas recommended by your clinician.”
“Serious side effects are rare, but prolonged use of potent steroids over large areas can affect how the body regulates its natural steroid hormones. If your symptoms worsen, if you develop signs of infection or if you are unsure about any side effects, contact your pharmacist or doctor for advice.”
“Occasionally, people who have used potent steroids for a long time may notice a flare when treatment is stopped. If this happens, seek medical advice rather than restarting the steroid yourself.”
Closing the consultation
Close the consultation by summarising what you have discussed. This allows you to emphasise the key points of the consultation.
Finally, thank the patient for their time and offer them a leaflet summarising key information about topical corticosteroids.
Dispose of PPE appropriately and wash your hands.
Reviewer
Dr Zoe Venables
Dermatology registrar
Editor
Dr Chris Jefferies
References
- Topical corticosteroids. 2023 Available from: [LINK]
- British Association of Dermatologists. Topical corticosteroids. 2024. Available from: [LINK]
- The Newcastle upon Tyne Hospitals. Topical corticosteroids. 2024. Available from: [LINK]
- National Library of Medicine. Topical Corticosteroids. 2025. Available from: [LINK]
- DermnetNZ. Topical steroid. 2016. Available from: [LINK]
- National Eczema Society. Topical steroids. Available from: [LINK]
- DermnetNZ. Corticosteroids. 2008. Available from: [LINK]
- DermnetNZ. Fingertip unit. 2023. Available from [LINK]
- DermnetNZ. Topical corticosteroid withdrawal. 2023. Available from: [LINK]
Image references
- Figure 1. DermnetNZ. Fingertip unit. Licence: [CC BY-NC-ND]
- Figure 2. DermnetNZ. Skin thinning from topical steroids. Licence: [CC BY-NC-ND]
- Figure 3. DermnetNZ. Steroid atrophy: striae. Licence: [CC BY-NC-ND]
- Figure 4. DermnetNZ. Perioral dermatitis. Licence: [CC BY-NC-ND]
- Figure 5. DermnetNZ. Perioral dermatitis. Licence: [CC BY-NC-ND]
- Figure 6. DermnetNZ. Steroid induced rosacea and pigmentation. Licence: [CC BY-NC-ND]
- Figure 7. DermnetNZ. Redness and swelling of the forearm. Licence: [CC BY-NC-ND]
Discover more from Bibliobazar Digi Books
Subscribe to get the latest posts sent to your email.
