Previous changes

August 2024 — minor update. Information relating to the potency of topical corticosteroids has been updated to reflect the new Medicines and Healthcare products Regulatory Agency (MHRA) potency labelling system for topical corticosteroids. 

July 2024 — minor update. A link to the Specialist Pharmacy Service (SPS) document Using inhaled and topical corticosteroids in breastfeeding has been added to the section on Pregnancy and breastfeeding. 

June 2022 — minor update. Additional information on the possibility of topical steroid withdrawal syndrome has been added to the Basis for recommendation section on withdrawal of topical corticosteroids in line with updated manufacturers' Summaries of Product Characteristics (SPCs).

September 2020 — minor update. The contraindications and cautions of corticosteroid eye preparations have been updated in line with manufacturers' SPCs.

June 2020 — reviewed. A literature search was conducted in June 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last version of this topic. There have been no major changes to the recommendations.

April 2020 — minor update. Table 5 in the section on Quantities to Prescribe was updated to clarify that the quantities refer to single daily use over a two-week period.

November 2018 — minor update: The strengths and formulations of topical corticosteroids have been updated in Table 2, and topical corticosteroids are now listed by potency class.

August 2017 — minor update. Information regarding adverse effects associated with oral corticosteroids has been added based on updates to manufacturers' SPCs. 

December 2016 — minor update. Information has been added that systemic adverse effects associated with oral corticosteroids may also occur with topical corticosteroids.

July to September 2015 — reviewed. A literature search was conducted in June 2015 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last version of this topic. There have been no major changes to the recommendations.

January 2011 — minor update. The topic title has been changed to Corticosteroids – topical (skin), nose, and eyes. The original title, Corticosteroids – topical (skin, nose, and eyes), was potentially misleading, as 'topical' in this context specifically refers to preparations used on the skin. Additionally, the term 'intraocular corticosteroids' has been replaced with 'corticosteroid eye preparations' throughout the document to reflect more accurate and appropriate terminology.

September 2010 — minor update. The MHRA has issued a reminder that intranasal corticosteroids may be associated with psychological and behavioural adverse effects.

April to August 2010 — this is a new CKS topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 June 2025.

HTAs (Health Technology Assessments)

No new HTAs since 1 June 2025.

Economic appraisals

No new economic appraisals relevant to England since 1 June 2025.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 June 2025.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 June 2025.

New policies

No new national policies or guidelines since 1 June 2025.

New safety alerts

No new safety alerts issued since 1 June 2025.

Changes in product availability

No changes in product availability since 1 June 2025.

Topical (skin) corticosteroids

• Topical corticosteroids are available in various formulations and potency levels.
  • The choice of formulation and potency depends on factors such as the type and severity of the condition, its location, cosmetic acceptability, and the person's preference.
  • Some topical corticosteroids are combined with other active ingredients to enhance effectiveness, including:
    • Antibacterials (such as fusidic acid or neomycin) — to treat or prevent secondary bacterial infections.
    • Antifungals (such as miconazole or clotrimazole) — to treat fungal infections alongside inflammation.
    • Keratolytics (such as salicylic acid) — to reduce scaling and improve steroid penetration.
• Available formulations of topical corticosteroids include [Stacey, 2021; BNF, 2025]:
  • Ointments:
    
    • Thick and greasy, with a prolonged emollient effect that can enhance steroid potency.
    • Occlusive and lubricating, thereby increasing absorption.
    • Usually preservative-free, making them less likely to irritate.
    • Preferred for dry, lichenified, or scaly conditions, or where a more occlusive effect is required.
    • Not suitable for hairy or intertriginous areas (such as the groin, gluteal cleft, and axilla), as they can promote folliculitis or maceration.
  • Creams:
    • Moisturizing without being greasy, making them cosmetically acceptable.
    • Vanish into the skin when applied.
    • Generally less potent than ointments with the same active ingredient.
    • Less occlusive than ointments.
    • Often contain preservatives, which may cause stinging or irritation.
    • Suitable for moist or weepy lesions.
  • Lotions:
    • Have higher water content than creams and are pourable.
    • Vanish into the skin when applied.
    • Less occlusive than creams.
    • Useful for hairy areas because they penetrate easily and leave little residue.
    • Often contain preservatives, which may cause stinging or irritation.
    • Can have a drying effect, which may be useful for acute exudative inflammation.
  • Gels:
    • Aqueous, dry rapidly, and leave little residue. 
    • Often sting when applied to inflamed, fissured, or eroded skin.
    • Useful for hairy areas or when the person wishes to avoid the greasy feeling of ointments, creams, and lotions.
    • Can have a drying effect.
  • Foams and shampoos:
    • Easy to apply and spread.
    • Convenient for use on hairy areas such as the scalp or beard.
    • Foams are usually more expensive.
  • Tapes:
    • Self‑adhesive dressings that deliver steroids directly to inflammatory skin lesions, while providing occlusion for enhanced efficacy.
    • Occlusion increases steroid absorption, which can increase the risk of local adverse effects (such as skin thinning, folliculitis, and telangiectasia).
    • Potent and very potent topical corticosteroids used under occlusion should be reserved for short-term use on areas of thick skin (such as the palms or soles) and prescribed under specialist supervision.
• Available potencies of topical corticosteroids are [BNF, 2025]:
  • Mild:
    • Hydrocortisone 0.1%, 0.5%, 1.0%, 2.5% (cream and ointment).
  • Moderate:
    • Alclometasone dipropionate 0.05% (cream and ointment).
    • Clobetasone butyrate 0.05% (cream and ointment).
    • Hydrocortisone butyrate 0.1% (cream, ointment, and scalp application).
  • Potent:
    • Beclometasone dipropionate 0.025% (cream and ointment).
    • Betamethasone dipropionate 0.05% (cream, ointment, and lotion).
    • Betamethasone valerate 0.025% (cream and ointment).
    • Betamethasone valerate 0.1% (cream, ointment, lotion, scalp application, and foam).
    • Fludroxycortide 0.0125% (cream, ointment, and tape).
    • Fluocinolone acetonide 0.00625% (cream and ointment).
    • Fluocinolone acetonide 0.025% (cream, ointment, and gel).
    • Fluocinonide 0.05% (cream and ointment).
    • Fluticasone propionate 0.05% (cream).
    • Mometasone furoate 0.1% (cream, ointment, and scalp application).
  • Very potent:
    • Clobetasol propionate 0.0525% (cream, ointment, scalp application, and foam).

Intranasal corticosteroids

• Intranasal corticosteroids are available as sprays and drops.
  • The choice of formulation depends on the person's preference, ease of use, and product availability.
  • Formulations vary in type (aqueous or non-aqueous), tolerability, and onset of action. 
  • The risk of systemic effects may be higher with nasal drops than with nasal sprays, as drops are more prone to incorrect administration.
  • Some intranasal corticosteroids are combined with antihistamines or decongestants to enhance symptom relief.
• The intranasal corticosteroids available in the UK include:
  • Beclometasone dipropionate (spray).
  • Betamethasone sodium phosphate (drops).
  • Budesonide (spray).
  • Fluticasone propionate (aqueous spray and drops).
  • Fluticasone furoate (aqueous spray).
  • Mometasone furoate (spray).
  • Triamcinolone acetonide (aqueous spray).  
• Combination products include:
  • Beclometasone dipropionate plus oxymetazoline (a decongestant).
  • Fluticasone propionate plus azelastine (an antihistamine).

[BNF, 2025]

Corticosteroid eye preparations

• Corticosteroid eye preparations are available as drops (solutions and suspensions), ointments, and preservative-free unit-dose drops.
  • The choice of formulation depends on the nature and severity of the condition being treated, as well as factors such as tolerability, ease of administration, and the person's preference.
  • Formulations differ in viscosity and onset of action, which influence dosing frequency and comfort. For example, drops are more fluid and easier to apply but may require more frequent dosing. In contrast, ointments are more viscous and stay longer on the eye but can cause blurred vision, making them more suitable for night-time use.
  • Some corticosteroid eye preparations are combined with antibacterials, particularly for post-surgical use or in cases of suspected infection.
• The corticosteroid eye preparations available in the UK include:
  • Betamethasone (drops).
  • Dexamethasone (drops and preservative-free unit-dose drops).
  • Fluorometholone (ophthalmic suspension).
  • Hydrocortisone sodium phosphate (preservative-free unit-dose drops).
  • Loteprednol etabonate (drops).
  • Prednisolone (drops and unit-dose drops).
• Combination products include:
  • Dexamethasone plus chloramphenicol.
  • Dexamethasone plus tobramycin.
  • Prednisolone plus neomycin plus polymyxin B.

[BNF, 2025]

What are the contraindications and cautions of topical corticosteroids?

• For all topical corticosteroids:
  • Do not prescribe:
    • For routine treatment of urticaria — treatment should only be initiated and supervised by a specialist. 
    • Indiscriminately for treating pruritus — topical corticosteroids are effective only when pruritus is caused by underlying inflammation.
  • Avoid use in people with:
    • Acne.
    • Perioral dermatitis.
    • Rosacea. 
    • Untreated bacterial, fungal, or viral skin lesions.
  • Prescribe with caution:
    
    • For application near the eyes (for example, to the eyelids) — care is needed to ensure the preparation does not enter the eye. Cataract and glaucoma may result from repeated exposure.
    • In pregnant or breastfeeding women.
• For potent or very potent topical corticosteroids:
  • Avoid use:
    • In people with widespread plaque psoriasis.
    • On the face and skin flexures — if indicated, limit use to short durations or seek specialist advice.
    • With occlusive dressings.
  • Prescribe under specialist supervision in:
    • Children and young people.
    • Adults with psoriasis — due to the risk of rebound relapse, generalized pustular psoriasis, and local and systemic toxicity.
• Be aware of factors that can increase systemic exposure to corticosteroids, and therefore the risk of systemic adverse effects, such as:
  
  • Age — children and older adults are more susceptible due to a thinner epidermis.
  • Steroid potency — systemic exposure increases with higher-potency topical corticosteroids.
  • Formulation — systemic absorption is greater with ointments than with creams, lotions, or gels due to their occlusive properties, which enhance skin hydration and drug penetration.
  • Frequency and duration of treatment — frequent application or prolonged use increases the likelihood of systemic exposure.
  • Surface area being treated — the larger the area, the greater the risk of systemic absorption.
  • Use under occlusion — dressings, nappies, or skin folds trap moisture, enhancing corticosteroid penetration.
  • Skin condition — greater absorption occurs in areas with naturally thin skin (such as the face, flexures, or genitals) or where the skin is inflamed, broken, moist, macerated, or ulcerated.
  • Concurrent corticosteroid treatment — systemic exposure increases when topical corticosteroids are used with other corticosteroid preparations (for example, oral or inhaled).
  • Concurrent use of an enzyme inhibitor — cytochrome P450 3A4 (CYP3A4) inhibitors, such as ritonavir, itraconazole, and ketoconazole, can reduce steroid metabolism and increase systemic corticosteroid levels.

What should I consider when initiating topical corticosteroids?

• When initiating topical corticosteroids:
  • Ensure there is a clear indication, such as eczema or psoriasis.
  • Check manufacturers' Summaries of Product Characteristics (SPCs) for licensing, prescribing, and dosing information. 
  • Consider contraindications and cautions.
  • Prescribe the least potent corticosteroid that effectively relieves symptoms. In general: 
    
    • Use mild or moderately potent corticosteroids for areas with thin or sensitive skin (such as the face, flexures, or genitals). 
    • Use more potent corticosteroids on thicker skin (such as palms or soles) or where there is lichenification from chronic scratching.
  • Treat for the shortest duration needed to effectively manage the condition.  
    
    • Topical steroids are generally used for 7–14 days, but shorter courses (for example, 5–7 days) are also common.
    • Treatment duration depends on factors such as the person's age, severity of the condition, and the body site affected.
    • Do not use potent corticosteroids continuously at any site for longer than 8 weeks.
    • Do not use very potent corticosteroids continuously at any site for longer than 4 weeks.
    • Aim for a break of 4 weeks between courses of treatment with potent or very potent corticosteroids.
    • Use intermittent treatment whenever possible, such as for eczema flares.
    • Consider intermittent use of corticosteroids for maintenance treatment, alternating with emollients alone.
  • Choose an appropriate formulation.
    • Consider factors such as the condition being treated, its severity and location, cosmetic acceptability, and the person's preference.
    • Be aware that formulation can influence the potency and absorption of topical corticosteroids. For example, ointments are generally more potent than creams, lotions, or gels.
  • Prescribe an appropriate quantity to avoid under- or over-treatment. In adults, the recommended quantities for a single daily application for 2 weeks are:
    • Face and neck: 15–30 g
    • Both hands: 15–30 g
    • Scalp: 15–30 g
    • Groins and genitalia: 15–30 g
    • Both arms: 30–60 g
    • Both legs: 100 g
    • Trunk: 100 g
  • Consider whether a steroid alert card is needed.
  • Provide clear information and advice to support safe use and reduce the risk of adverse effects.
  • Plan appropriate monitoring and follow up to assess treatment response and check for adverse effects. 

Can I prescribe topical corticosteroids to a woman who is pregnant or breastfeeding?

• Pregnancy
  • Topical corticosteroids may be used in pregnancy if the benefits to the mother and child outweigh the potential risks.
• Breastfeeding
  • Topical corticosteroids may be used during breastfeeding if the benefits to the mother and child outweigh the potential risks.
  • If corticosteroids are needed on the breast:
    • Consider prescribing creams instead of ointments, as creams are easier to remove.
    • Use the least potent preparation appropriate for the condition and for the shortest possible duration.
    • Choose mild to moderate potency corticosteroids for application on the nipple and areola; avoid higher potencies.
    • Advise the woman to gently wash off the corticosteroid with warm water from all areas of the breast, especially the nipples and areola, before breastfeeding, to prevent the infant’s mouth from coming into contact with the medication.

What are the adverse effects of topical corticosteroids?

• Local adverse effects are more common with topical steroids. They include:
  
  • Acne vulgaris.
  • Folliculitis. 
  • Skin atrophy (thinning). 
  • Telangiectasia.
  • Transient burning or stinging.
  • Permanent striae. 
  • Allergic contact dermatitis.
  • Exacerbation of rosacea, perioral dermatitis, or tinea infections. 
  • Skin depigmentation — usually reversible. 
  • Excessive hair growth at the site of application (hypertrichosis). 
  • Vasodilation.
• Systemic adverse effects can occur when significant amounts of topical corticosteroids are absorbed through the skin or when systemic exposure to corticosteroids is increased by other factors, such as concurrent use of other corticosteroid preparations. 
  • Systemic effects include: 
    • Adrenal suppression.
    • Cushing's syndrome.
    • Osteoporosis.
    • Blurred vision or other visual disturbances (often secondary to cataract or glaucoma, and, rarely, central serous chorioretinopathy).
    • Growth retardation (in children and adolescents).
    • Rarely, psychological or behavioural effects, such as psychomotor hyperactivity, sleep disorders, anxiety, depression, or aggression (particularly in children). 
  • For more information on the systematic adverse effects of corticosteroids, see the section on Adverse effects in the CKS topic on Corticosteroids - oral.
• Topical steroid withdrawal (TSW) reactions are rare adverse effects that can occur with long-term or inappropriate use of topical corticosteroids, particularly moderate to high potency.
  • They typically develop after application of a topical corticosteroid at least daily for over a year, but can appear within 2 months in children. People with atopic dermatitis are at higher risk.
  • The most common reaction is a rebound (or flare) of the original skin condition. Rarely, a specific type of withdrawal reaction can occur, in which skin redness extends beyond the initial area of treatment, accompanied by burning or stinging that is worse than the original condition.
  • TSW can be hard to distinguish from a flare, but it is more likely if:
    
    • Burning is the main symptom, rather than itching.
    • Redness is confluent rather than patchy (less obvious on darker skin).
    • The rash resembles atopic dermatitis but affects unusual sites or looks different from previous episodes.
    • There is a history of prolonged use of moderate- or high-potency topical corticosteroids.
  • If the skin condition fails to improve, and before escalating to a more potent corticosteroid, alternative diagnoses, such as rosacea, infection, and contact allergy, should be considered. Patch testing may help identify some cases of contact allergy. 
  • If severe rebound atopic dermatitis is suspected, specialist referral should be arranged. 
  • The National Eczema Society and British dermatology groups have produced a Joint Statement on Topical Steroid Withdrawal, which outlines these reactions. 

How can I reduce the risk of adverse effects of topical corticosteroids?

• To reduce the risk of adverse effects of topical corticosteroids:
  • Prescribe the lowest effective potency using an appropriate formulation, quantity, and duration. For more information, see the section on Initiation.
  • Be aware of other factors that can increase systemic exposure to corticosteroids, and therefore the risk of systemic adverse effects, such as concurrent use of other corticosteroid preparations (for example, oral or inhaled).
  • Gradually withdraw treatment when stopping to help maintain disease control. Consider the following options:
    • Reduce the application frequency of the current corticosteroid. 
    • Step down to a lower potency corticosteroid. 
    • Use a lower potency corticosteroid intermittently.
  • In children and adolescents receiving prolonged high-potency treatment or with additional risk factors for systemic exposure: 
    
    • Monitor height accurately and regularly (at least annually) using a growth chart.
    • Refer to a paediatrician if growth suppression is suspected.
  • Provide clear information and advice to support safe use and reduce the risk of adverse effects.

What information and advice should I give to a person receiving topical corticosteroids?

• Ensure that the person knows how to use the topical corticosteroid safely and effectively.
  • Advise them to read the patient information leaflet (PIL) provided with the medicine. Additionally, the National Eczema Society has a factsheet on Topical Steroids.
  • Explain that they should: 
    • Apply a thin layer once or twice daily as directed.
    • Use a sufficient amount to prevent under-treatment — fingertip units can help guide how much to apply.
    • Rub in gently, following the direction of hair growth to reduce irritation, such as folliculitis.
    • Use the treatment for the recommended duration, especially on sensitive areas like the face and genitals.
    • Wait 20–30 minutes between applying an emollient and the corticosteroid to avoid diluting the medication.
    • Seek advice before using the corticosteroid on a new skin area, as some areas may require a different topical steroid.
    • If prescribed more than one topical steroid for different body areas, ensure they use the correct strength for each specific area. 
    • Contact a healthcare professional if their condition worsens. Explain when it would be appropriate to restart treatment without a consultation.
    • Avoid restarting treatment within 2 weeks of stopping unless advised to do so by their doctor.
• Discuss the possible adverse effects of topical corticosteroids.
  • Reassure the person that when used correctly, topical corticosteroids rarely cause serious adverse effects.
  • Advise that they should:
    • Seek medical review if they experience local adverse effects, such as thinning of the skin, striae, or acne vulgaris. 
    • Be alert for the symptoms of adrenal insufficiency (such as dizziness, nausea, lethargy, and hypotension) and seek urgent medical attention if these occur. For more information, see the section on Adrenal insufficiency in the CKS topic on Corticosteroids - oral.
    • Seek medical advice if they experience other adverse effects, such as visual disturbances and mood or behavioural changes. 
    • Attend all review appointments with the primary care team and, if applicable, their specialist to ensure appropriate monitoring and effective management of their condition.
    • Avoid fire or other naked flames (for example, candles and cigarettes), as topical corticosteroids can soak into dressings, clothing, and bedding, making the fabric flammable.
    • Discard out-of-date topical preparations, as reusing a microbially contaminated corticosteroid can be harmful.
  • Explain that topical steroid withdrawal (TSW) reactions may occur after stopping long-term or inappropriate topical corticosteroid use. 
    • Advise them to seek medical review before restarting treatment if their condition returns with redness that extends beyond the original treatment area, especially if accompanied by burning or stinging sensations.
    • They should also seek review if symptoms develop after stopping treatment, such as redness, skin darkening or greying (in darker skin), burning, stinging, itching, peeling, oozing, or open sores, particularly if these occur beyond the initially treated area.
    • The Medicines and Healthcare products Regulatory Agency (MHRA) has developed a Patient Safety Leaflet on topical corticosteroids and withdrawal reactions. 
• If the person is on prolonged high-potency treatment or has additional risk factors for systemic exposure (such as concurrent use of other corticosteroids), advise them to:
  
  • Carry a Steroid Treatment Card (Blue) and/or a Steroid Emergency Card (Red), as appropriate.
  • Follow sick day rules advice during illness or physical stress, if applicable.
  • Seek prompt medical advice if they become unwell or are exposed to an infectious disease, such as measles.
  • Avoid close contact with anyone who has chickenpox or shingles if they have never had chickenpox, and seek medical advice if exposed.

What are the contraindications and cautions of intranasal corticosteroids?

• Avoid intranasal corticosteroids:
  • After nasal surgery (until healing has occurred).
  • In people with:
    • Untreated nasal infections (until the infection has been appropriately treated).
    • Pulmonary tuberculosis.
    • Predisposition to high ocular pressure or glaucoma.
• Prescribe intranasal corticosteroids with caution in:
  
  • Pregnant or breastfeeding women.
• Be aware of factors that increase systemic exposure to corticosteroids, and therefore the risk of systemic adverse effects, such as:
  
  • Age — children and older adults are more susceptible due to thinner mucosal and dermal barriers.
  • Steroid properties — intranasal corticosteroids vary in receptor affinity and systemic bioavailability, which can influence systemic exposure.
  • Formulation — sytemic absorption is higher with drops than sprays, as drops are more prone to incorrect administration.
  • Treatment dosage and duration — higher doses and longer or more frequent use increase systemic exposure.
  • Concurrent corticosteroid treatment — systemic exposure increases when intranasal corticosteroids are used with other corticosteroid preparations (for example, oral or inhaled).
  • Concurrent use of an enzyme inhibitor — cytochrome P450 3A4 (CYP3A4) inhibitors, such as ritonavir, itraconazole, and ketoconazole, can reduce steroid metabolism and increase systemic corticosteroid levels.

What should I consider when initiating intranasal corticosteroids?

• When initiating intranasal corticosteroids:
  • Ensure there is a clear indication, such as allergic rhinitis.
  • Check the manufacturers' Summaries of Product Characteristics (SPCs) for licensing, prescribing, and dosing information. 
  • Consider contraindications and cautions.
  • Prescribe the lowest effective dose for the shortest possible duration.
  • Choose an appropriate product. 
    • In adults, consider factors such as the condition being treated, systemic drug bioavailability, cost, and ease of device use.
    • In children, mometasone furoate, fluticasone furoate, and fluticasone propionate are preferred due to their negligible systemic absorption. Betamethasone shows high systemic absorption and should be reserved for short-term use only. Other preparations have modest systemic absorption.
    • Note that systemic absorption is higher with drops than sprays, as drops are more prone to incorrect administration.
  • Consider whether a steroid alert card is needed.
  • Provide clear information and advice to support safe use and reduce the risk of adverse effects.
  • Plan appropriate monitoring and follow up to assess treatment response and check for adverse effects.

Can I prescribe intranasal corticosteroids to a woman who is pregnant or breastfeeding?

• Pregnancy
  • Intranasal corticosteroids can be used in pregnancy if the benefits to the mother and child outweigh the potential risks.
• Breastfeeding
  • Intranasal corticosteroids can be used during breastfeeding if the benefits to the mother and child outweigh the potential risks.

What are the adverse effects of intranasal corticosteroids?

• Local adverse effects are more common with intranasal corticosteroids. They include: 
  • Nasal dryness, burning, irritation, or ulceration.
  • Nosebleeds.
  • Throat dryness and irritation.
  • Disturbance of smell and taste.
  • Nasal septal perforation (very rare).
• Systemic adverse effects can occur with prolonged high-dose treatment or when systemic exposure is increased by other factors, such as concurrent use of other corticosteroid preparations. 
  • Systemic effects include: 
    • Adrenal suppression.
    • Cushing's syndrome.
    • Blurred vision or other visual disturbances (often secondary to cataract or glaucoma, and, rarely, central serous chorioretinopathy).
    • Growth retardation (in children and adolescents).
    • Rarely, psychological or behavioural effects, such as psychomotor hyperactivity, sleep disorders, anxiety, depression, or aggression (particularly in children). 
  • For more information on the systematic adverse effects of corticosteroids, see the section on Adverse effects in the CKS topic on Corticosteroids - oral.

How can I reduce the risk of adverse effects of intranasal corticosteroids?

• To reduce the risk of adverse effects of intranasal corticosteroids:
  • Prescribe the lowest effective dose for the shortest possible duration.
  • Prescribe nasal sprays instead of drops, as drops are more likely to be administered incorrectly, leading to greater systemic absorption.
  • Be aware of other factors that increase systemic exposure to corticosteroids, and therefore the risk of systemic adverse effects, such as concurrent use of other corticosteroid preparations (for example, oral or inhaled).
  • Consider a benzalkonium-free preparation for people who experience nasal irritation (for example, Flixonase Nasules®). 
  • In children and adolescents receiving prolonged high-dose treatment or with additional risk factors for systemic exposure to corticosteroids: 
    
    • Monitor height accurately and regularly (at least annually) using a growth chart.
    • Refer to a paediatrician if growth suppression is suspected.
  • Provide clear information and advice to support safe use and reduce the risk of adverse effects.

What information and advice should I give to a person receiving intranasal corticosteroids?

• Ensure that the person knows how to use the intranasal corticosteroid safely and effectively.
  • Advise them to read the patient information leaflet (PIL) provided with the medicine.
  • Explain that:
    
    • Intranasal corticosteroids should be used regularly, once or twice daily, to control symptoms effectively.
    • They may not notice any benefit from the treatment for a few days, and the maximal effect may not be apparent until after a few weeks. 
• Discuss the possible adverse effects of intranasal corticosteroids.
  • Reassure the person that, when used correctly, intranasal corticosteroids rarely cause serious adverse effects.
  • Advise that they should:
    • Seek medical review if they experience local adverse effects, such as nosebleeds or nasal irritation. 
    • Be alert for the symptoms of adrenal insufficiency (such as dizziness, nausea, lethargy, and hypotension) and seek urgent medical attention if these occur. For more information, see the section on Adrenal insufficiency in the CKS topic on Corticosteroids - oral.
    • Seek medical advice if they experience other adverse effects, such as visual disturbances and mood or behavioural changes.
    • Attend all review appointments with the primary care team and, if applicable, their specialist to ensure appropriate monitoring and effective management of their condition.
• If the person is on prolonged high-dose treatment or has additional risk factors for systemic exposure (such as concurrent use of other corticosteroids), advise them to:  
  • Carry a Steroid Treatment Card (Blue) and/or a Steroid Emergency Card (Red), as appropriate.
  • Follow sick day rules advice during illness or physical stress, if applicable.
  • Seek prompt medical advice if they become unwell or are exposed to an infectious disease, such as measles.
  • Avoid close contact with anyone who has chickenpox or shingles if they have never had chickenpox, and seek medical advice if exposed.

What should I know about the initiation of corticosteroid eye preparations?

• Corticosteroid eye preparations are usually initiated in secondary care by a specialist. However, treatment may be continued and monitored in primary care under a shared care protocol.

What are the adverse effects of corticosteroid eye preparations?

• Local adverse effects include:
  
  • Increased intraocular pressure.
  • Eye discomfort, irritation, burning, stinging, or itching.
  • Blurred vision or other visual disturbances (often secondary to cataract or glaucoma, and, rarely, central serous chorioretinopathy).
  • Allergic and hypersensitivity reactions.
  • Delayed wound healing.
  • Increased susceptibility to bacterial, viral, and fungal eye infections.
  • Very rarely, conjunctivitis, mydriasis, facial oedema, ptosis, corticosteroid-induced uveitis, corneal calcifications, crystalline keratopathy, changes in corneal thickness, corneal oedema, corneal ulceration, and corneal perforation.
• Systemic adverse effects may occur with prolonged high-dose treatment.
  
  • They include:  
    • Adrenal suppression.
    • Cushing's syndrome.
    • Growth retardation (in children and adolescents).
    • Rarely, psychological or behavioural effects, such as psychomotor hyperactivity, sleep disorders, anxiety, depression, or aggression (particularly in children). 
  • Systemic effects may be due to absorption of corticosteroid eye preparations into the general circulation, either directly through the conjunctiva or via drainage into the nasal cavity through the tear ducts.
    • The extent of systemic absorption is highly variable and is influenced by factors such as nasolacrimal drainage, blink rate, and tear turnover.
    • Applying pressure to the lacrimal punctum for at least one minute after instilling corticosteroid eye drops can reduce nasolacrimal drainage and, therefore, lower the risk of systemic absorption.
  • Other risk factors for increased systemic exposure include:
    • Age — children are subject to a much higher risk of systemic adverse effects because ocular dosing is not weight-adjusted, and their physiological development (for example, liver status) differs from that of adults. Older adults are also vulnerable due to age-related pharmacokinetic differences.
    • Steroid properties — corticosteroid eye preparations vary in potency, lipophilicity, and systemic bioavailability, which can influence systemic exposure.
    • Formulation — systemic absorption varies with the type of formulation. For example, nasal drainage is associated with eye drops much more often than with eye ointments.
    • Frequency and duration of treatment — frequent or prolonged use increases the likelihood of systemic exposure.
    • Concurrent corticosteroid treatment — systemic exposure increases when corticosteroid eye preparations are used with other corticosteroids (for example, oral or inhaled).
    • Concurrent use of an enzyme inhibitor — cytochrome P450 3A4 (CYP3A4) inhibitors, such as ritonavir, itraconazole, and ketoconazole, can reduce steroid metabolism and increase systemic corticosteroid levels.
  • For more information on the systematic adverse effects of corticosteroids, see the section on Adverse effects in the CKS topic on Corticosteroids - oral.

What information and advice should I give to a person using corticosteroid eye preparations?

• Ensure the person knows how to use the product.
  • Advise them to:
    • Use the medicine as directed by the specialist.
    • Read the patient information leaflet (PIL) provided with the medicine.
  • Explain that:
    • Eye drops and ointments may temporarily blur vision. If affected, they should not drive or perform other skilled tasks until their vision is clear.
    • When two different eye preparations are used at the same time of day, there should be an interval of at least 5 minutes between them to allow the first to be fully absorbed; eye ointment should be applied after drops.
    • Applying pressure to the lacrimal punctum for at least one minute after administering eye drops reduces nasolacrimal drainage, decreasing systemic absorption from the nasal mucosa.
    • Eye-drop dispenser devices are available to aid the instillation of eye drops from plastic bottles.
  • For contact lens users, advise that:
    • Soft contact lenses should be removed before using eye drops unless medically indicated, as preservatives can accumulate in the lenses and cause irritation; unpreserved drops are preferred. Ointments and oily drops should not be used with soft lenses due to the risk of lens deposits.
    • Hard contact lenses should ideally be removed before using eye drops (but may be left in if necessary). Ointments and oily drops should be avoided, as they can cause lens deposits.
• Discuss the possible adverse effects of corticosteroid eye preparations.
  • Reassure the person that, when used correctly, corticosteroid eye preparations rarely cause serious adverse effects.
  • Advise that they should:
    
    • Seek medical review if they experience local adverse effects, such as eye discomfort, irritation, burning, stinging, or itching.
    • Be alert for the symptoms of adrenal insufficiency (such as dizziness, nausea, lethargy, and hypotension) and seek urgent medical attention if these occur. For more information, see the section on Adrenal insufficiency in the CKS topic on Corticosteroids - oral.
    • Seek medical advice if they experience other adverse effects, such as visual disturbances and mood or behavioural changes.
    • Attend all review appointments with their specialist to ensure safe monitoring and effective management of their condition.
• If the person is on prolonged high-dose treatment or has additional risk factors for systemic exposure (such as concurrent use of other corticosteroids), advise them to:   
  • Carry a Steroid Treatment Card (Blue) and/or a Steroid Emergency Card (Red), as appropriate.
  • Follow sick day rules advice during illness or physical stress, if applicable.
  • Seek prompt medical advice if they become unwell or are exposed to an infectious disease, such as measles.
  • Avoid close contact with anyone who has chickenpox or shingles if they have never had chickenpox, and seek medical advice if exposed.