Looking at the conversations on parenting forums, it’s clear that many parents have concerns over using prescribed hydrocortisone cream and other topical corticosteroids (TCS) in managing their child’s eczema.
In fact, there is so much anxiety around the use of TCS, that doctors have a term for it: ‘steroid phobia’.
A 2019 study into steroid phobia surveyed 3000 general users of corticosteroids and found that 31 per cent had steroid phobia.
In Korea, a similar study was carried out, this one specifically surveying parents of children with eczema, and 67.5 per cent of parents showed steroid phobia.
A medical survey in Italy discovered that 81 per cent of parents feared topical corticosteroids.
As a result of this phobia, lots of children are under-treated resulting in longer flare-ups and increased complications such as infections. So, to address this very real fear and combat under-treatment, we have teamed up with Dr Sam Hunt, consultant dermatologist at the Royal Hampshire County Hospital, to look at the research into the safety of these creams and how best to use them.
Treating childhood eczema: the basics
As the parent of an eczema child, you know that the mainstay of treatment for eczema is complete emollient therapy – moisturising creams and products that can be added to the bath water, used to wash the skin and then also to moisturise the skin.
Emollients should be used continuously even when the skin is good and the eczema is under control – as it often reduces the need for topical corticosteroids.
However, when a flare-up occurs, emollients by themselves are often not enough to control the itch that is characteristic of eczema. The itching causes children to scratch and this can cause significant damage to their already fragile skin.
The aim of topical corticosteroid treatment is to bring eczema flare-ups back under control as quickly as possible.
According to advice from the NHS, children are prescribed topical steroids to reduce inflammation, speed up healing of the skin, reduce discomfort and redness of the skin, minimise the risk of complications like skin infections, and avoid the need for stronger TCS treatments in the future.
Many studies have shown that used appropriately, the symptoms of eczema can be rapidly controlled without side effects.
What are topical corticosteroids and why are they scary?
According to the NHS, the main purpose of topical corticosteroids is to reduce skin inflammation and irritation. They are available in different forms, including creams, gels, and ointments.
Topical corticosteroids are creams, gels or ointments containing corticosteroids. Corticosteroids are hormones that can reduce inflammation (redness and swelling), suppress the immune system and narrow the blood vessels in the skin. Their main purpose is to reduce skin inflammation and irritation.
Prescribed TCS treatments range in strength from very mild (hydrocortisone) to super potent (clobetasol propionate-Dermovate) with gradations in between. GPs will typically prescribe very mild to moderate TCS creams for short periods (up to around 2-4 weeks) but refer your child to a consultant if stronger or more prolonged treatments are needed.
There has been a lot of bad publicity about cortisone creams in recent years. The reasons for this are wide-ranging; from misinformation and horror stories on the internet right up to advice from trusted sources who are unsure of how to use the products correctly.
In addition, chemists are duty-bound to warn you of all possible side effects. They are completely in the right when they do this but it can sound alarming. If you are concerned it is always better to call your doctor to double-check the information rather than just not using the prescription.
The side effects that people worry about are thinning of the skin and suppression of the bodies own natural production of steroids which could affect growth. It is worth noting that there is a huge difference between the creams prescribed for eczema and high doses of cortisone taken orally.
There is also concern about the use of steroids on the face, particularly around the eyes. The reason for this is that if hydrocortisone or other steroids get into the eyes they can cause increased pressure within the eyeball.
According to an advice leaflet issued by the NHS, ‘A number of studies have been done to look at the benefit of using topical steroids in eczema versus the potential harm from side effects.
The National Institute for Clinical Excellence (NICE) looked at these studies together, and concluded that the benefit of using topical steroids in eczema outweighs the potential harm from side effects when used correctly.’
Are TCS creams, like hydrocortisone, safe to use on children?
There are many studies, including this study from 2016, into the long-term safety of topical corticosteroids in paediatric patients.
Here is another study on the ‘safety of topical corticosteroids in atopic eczema’ that shows the use of mild to moderate potency steroids does not cause thinning of the skin or suppression of a child’s own corticosteroids.
These studies support the long-term safety of TCI and low to mid-potency TCS therapy in children with atopic dermatitis.
Studies looking at the use of a mild steroid – Hydrocortisone applied daily twice daily for 6 weeks versus a moderate potency steroid (mometasone furoate) applied once daily for six weeks found that there was a significant benefit with the moderately potent steroid in that eczema, in particular the itching, was more rapidly controlled than with the mild steroid.
No skin thinning or suppression of the body’s own steroid was seen in either group. Here’s a link to the published paper.
How to use hydrocortisone and TCS creams safely
One of the key aims of treatment in atopic dermatitis is to break the itch / scratch cycle.
When the skin is itching the child then scratches causing damage to the barrier function of the skin, the skin gets more itchy, the child scratches more, the skin gets more itchy and so it goes on.
This can be further exacerbated if there is a secondary infection and the itch /scratch cycle spirals out of control leading to significant upset for the child and sometimes resulting in time lost from school or even admission to hospital if things are very severe.
Dr Hunt recommends using mild or moderately potent steroids as soon as the skin starts to flare.
The aim of this approach is to bring things back under control quickly.
Waiting for the skin to deteriorate beyond what is tolerable often results in the need for stronger and longer steroid treatments.
In the words of one of our eczema nurses, you should use enough steroid cream to make the skin glisten and continue to use the eczema hydrocortisone cream for a couple of days after the skin has healed.
Dr Hunt’s Approach to prescribing TCS treatments
While every case is different, if the eczema is severe I normally recommend the use of a moderately potent steroid such as mometasone (Elcon) used once daily for a period of up to two weeks, I then use it alternate days for a week and then step down to the mild steroid, hydrocortisone used as and when needed.
If there is a significant flare subsequently, I recommend stepping back up to the stronger steroid to regain control and then gradually coming back down again.
If there is a significant flare and the skin is infected then antibiotics may be used in addition to the emollients and topical steroids.
Antihistamines are also useful and there are non-sedating products for use in the daytime like Piriteze and sedating products for the nighttime like Piriton – which can help with sleep.
In addition to emollients, topical steroids and antihistamines, the use of wet wraps, cotton garments, cotton gloves and anti-scratch clothing like ScratchSleeves may be useful in soothing the skin and avoiding further damage to the skin.
If your child is still struggling despite the use of all these measures please ask your GP to refer you to a dermatologist.