This is probably the most frequent question I hear from moms of children with eczema. There is a lot of myths and fear surrounding steroids.
I totally get the concern. I was there 6 years ago with my son, asking the same questions.
Thomas had really severe eczema. From the age of 3 weeks until around 9 months, I don’t think I saw normal skin on him – he was absolutely covered head to toe in aggressive, red eczema. As a mom, you are conditioned to love your child no matter what, but every time I undressed him, my heart broke looking at the bleeding raw skin that kept him up at night and constantly caused him discomfort. And yet when I held that tube of steroid cream in my hand, I hesitated.
Names of medications always confuse people – especially creams because the names are long! I have written a spiel at the end of the article on how to read names of creams (a bit boring if you already know but read this first before you go on if you don’t).
Now some tips to help you make up your mind:
- Eczema is best treated from the root (see my other article on the gut/skin relationship) – but treating the root is always slow. Thomas only grew out of his eczema completely at the age of 3 years. So if your child is having an acute flare, steroids are very good at getting the inflammation down rapidly. I see it as a bridging treatment – to get the skin under control while you work on root causes. It has been shown that poorly treated eczema skin may expose the child to a higher risk of food allergies as the broken skin barrier may allow food sensitization through the skin.
- Steroids do come with side effects. However, if you use it properly, side effects are rare.
- By properly – I mean, the right strength of steroid, for the right part of the body, for the right duration. The combination of these 3 factors will determine the effect of the steroid and its concentration in the bloodstream, if any.
- Steroids come in different strengths, from Class I (super potent) to Class V (weak), and a spectrum of different strengths in between. There’s too many to list, but to look up the strength of the particular steroid your doctor has prescribed, click here (USA), and here (UK). However, for infants it is best to stick to Class IV or V, and toddlers can probably have up to class III but only for short periods of time.
- A weak steroid (class V, such as hydrocortisone) is least likely to cause side effects, but may not be strong enough if the eczema is severe. It is available to buy over the counter but usually only as a cream and not ointment (see below differentiation between creams and ointments).
- A super potent steroid (Class I e.g. dermovate/tenovate) is more likely to cause side effects and be active in the bloodstream so make sure its use is not prolonged if prescribed. We sometimes used it in very severe eczema to gain rapid control over 2-3 days, then wean down to a Class III steroid.
- As a general rule, you should use weak steroids on areas of the body with thin skin to avoid side effects. Areas of the body with thin skin are: face (especially eyelids), back of the hand, groin. I have seen Clobetasol diproprionate (dermovate, tenovate) prescribed for groin and face just because the doctor didn’t understand the different strength of steroids, and it is scary as these are the strongest steroids available. Don’t be shy to question your doctor if you feel the strength of steroid they have prescribed is too strong. Use this page and the resources I’ve linked here to back up your case. They may have a good reason in which that’s fine but make sure they know what they are doing.
- Steroids come in many types of preparations: creams, ointments, foam and solutions. Steroid creams are better for weeping/infected eczema as it is drying. Steroid ointments are better for dry, inflamed eczema as it is moisturizing. Make sure you get the correct preparation from your doctor as many of them actually don’t know the difference. Every steroid cream will have an ointment and a cream preparation, make sure you check.
- If steroids are applied under occlusion e.g. wet wrap, or in skin folds like the armpit or groin grease (skin folds ACT as occlusion even though you are not occluding the skin) their strength increases. Be careful because if you are using medium strength under occlusion that effectively becomes potent strength steroid through occlusion.
- Most parents worry about steroids inhibiting growth in children. Unless your child is using lots of steroids, this is an unlikely side effect because systemic absorption is low, and the weaker the strength, the lower the concentration in the blood stream. Poorly treated eczema, however, can also cause growth impairment as lots of protein is lost through a broken skin barrier. This loss of protein may then impair body function and growth. So it is BETTER to treat eczema and maintain good skin control than to under treat.
- There are some local side effects of long-term steroid use on the skin too but this comes with prolonged use on normal skin: thinning, pigmentation change (lighter or darker), enlarged blood vessels and stretch marks. If you are treating active eczema, these local side effects are rare, especially if you stop once the skin improves.
- How much steroid should I apply? is another common question. click here to see the finger tip rule. This gives you a guide on how much body area a fingertip worth of steroids should cover for each age group in kids.
- Steroids are often combined with an antibiotic e.g. fucidin – because eczema often becomes infected. If your child’s skin is NOT infected, however, please avoid the use of an antibiotic because this leads to antibiotic resistance which is no rampant, which means when your child REALLY needs an antibiotic for an infection, it won’t work so well. The dose of amoxicillin necessary to treat infections has now doubled in order to overcome antibiotic resistance. Think about the toxic effect this is having on your body.
- When you start to see the skin improve, you can reduce steroid use to every other day, and then stop when the skin is clear. It is important then to replace steroids with regular moisturizing (4-5 times a day) to prevent flare ups upon stopping steroids.
- Steroids are best applied straight after a shower/bath. But make sure you leave a 10-15min gap between steroids and moisturizers so they don’t just sit on top of each other and rub off on clothes.
- If your child’s skin does not improve after 1-2 weeks of steroid treatment, you must see the doctor instead of continuing.
How to read names of creams
Once you know how steroids are named you can look up their strength on the internet, communicate better with your doctor, and be self-empowered so it is good to learn this even though it’s a bit boring.
So bear with me….. With any medicines, there are usually two names. One is the generic – and this is basically the name of the drug itself. The other is the trade name – this is the name given to the drug by the drug company. Analogy: think about cornflakes. ‘Cornflakes’ is the generic name for cornflakes. But Kellog’s Crunchy nut, Nature’s path cornflakes, Kashi’s cornflakes – these underlined names are the trade names (because it depends on the company who manufactures them). But ultimately the active ingredient is the same – cornflakes. With creams, it is usually easier to look at the trade names because they are shorter but sometimes it is helpful to know what the active ingredient is. Because that is often what is found online although you can now find many trade names online too. One tip if you are looking at the generic is you should look at the WHOLE name and not just the first bit.
E.g.When you look at the cream below – it says Tenovate (trade name) and also clobetasol proprionate (generic name)
Now look at this picture below – it says Eumovate (trade name) and Clobetasol butyrate (generic name)
What do you notice? They both start with Clobetasol right? but one is the strongest steroid on the market, where as the other is a mild steroid. So the whole name matters, don’t just look at the first bit – this is important if you are looking up a cream on the internet to find out it’s potency.