Balancing Topical Steroids and Nonsteroidal Treatments in Kids’ Skin Care
Why this matters
Topical corticosteroid creams and ointments are a common tool for treating rashes in children. Lately, though, parents and patients have been more worried than ever about using them. A recent episode of the podcast “Don’t Be Rash” featured two pediatric dermatologists talking about when steroids make sense, how strong they are, safer ways to use them, and what nonsteroid options are now available for kids. This article summarizes that conversation in plain language so families can better understand their choices. (Source: Don’t Be Rash podcast interview)
A quick plain-language summary
Some people have a strong fear of topical steroids, driven in part by social media. True withdrawal from topical steroids is real but rare. Steroid strength depends on the drug itself, how concentrated it is, and the cream or ointment it’s mixed into. Many rashes do well with limited, carefully measured steroid use. New nonsteroidal creams are expanding options, especially for maintenance or for areas where steroids aren’t ideal. Always talk with your child’s dermatologist or doctor about the best plan.
What people mean by “steroid phobia” and topical steroid withdrawal
Steroid phobia is when someone worries a lot about harmful effects from topical steroids. Social media has made these worries louder. The podcast hosts noted that videos about topical steroid withdrawal and “addiction” have been downloaded billions of times on TikTok, which raises anxiety among families. (Source: Don’t Be Rash podcast interview)
Topical steroid withdrawal means a real, sometimes painful skin reaction that can happen after long, frequent use of very strong topical steroids. The doctors on the podcast said true cases are uncommon; one speaker has seen only two classic cases, both in adults who used the strongest steroid for a long time. Still, many families worry even after using small amounts.
How steroid strength (potency) works
In the U.S., topical steroid strength is grouped from class 1 (strongest) to class 7 (weakest). This system is based on a lab test called a vasoconstrictor assay, which predicts how strong the medicine is and how likely side effects might be. (Source: Don’t Be Rash podcast interview)
Don’t be fooled by percentages. For example, clobetasol at 0.05% is many times stronger than hydrocortisone 1%. The podcast cited a useful comparison: clobetasol 0.05% can be roughly 1,600 to 2,200 times stronger than hydrocortisone 1%.
The cream or ointment matters, too. The same active drug can fall into different potency classes depending on its vehicle. For instance, mometasone in an ointment can be class 2 (stronger), while the cream form of the same drug may be class 4 (weaker). Because of this variability, the doctors recommended learning a few trusted products well instead of trying to compare every option on your own. (Source: Don’t Be Rash podcast interview)
How doctors think about dosing and frequency
Daily routine matters more than tiny timing differences. Once-daily application of topical steroids often works about as well as twice-daily use in everyday life. Some doctors start with twice daily to get faster control of an itchy or painful flare, and then step down to once daily or stop when the skin improves. Applying a steroid more than twice a day rarely helps.
Prescriptions are often written by volume. That means the dermatologist estimates how many grams of cream or ointment your child will need for a two-week period, based on your child’s age and how much of the body is involved. Doctors sometimes ask families to bring the tube back at follow-up so they can check how much was used. If a child needs more than two or three applications per week just to keep things controlled, that’s a clue the care team should consider nonsteroidal options. (Source: Don’t Be Rash podcast interview)
Where on the body and how long affect choice of steroid
Skin thickness and location change the risk and benefit of steroids. Thin or delicate skin is more prone to thinning (known as atrophy), so steroids are used more cautiously there.
- Delicate areas such as around the eyes and in skin folds are usually treated with short courses of mild steroids, then switched to other options if needed.
- Thicker or tougher areas like lichenified plaques (thickened, leathery patches), the hands, and the feet often need stronger agents for good effect.
- Atrophic skin, where the skin has already thinned, is a reason to avoid steroids.
One condition called lichen sclerosus (a chronic inflammatory condition that can affect the genital skin) is an exception where powerful, pulse-style steroid treatment with class 1 agents is commonly used. Follow-up studies show that some adults treated for this condition in childhood can have ongoing disease and anatomic or sexual complications, so careful, long-term management is important. The doctors mentioned that nonsteroidal options, including different kinds of JAK inhibitors, are being developed for this condition. (Source: Don’t Be Rash podcast interview)
New nonsteroidal creams and what they mean
Several nonsteroidal topical medications are now available for children, which gives doctors more choices beyond corticosteroids. The podcast discussed these examples:
- Roflumilast cream (Zoryve), a PDE4 inhibitor, is available at 0.05% for children aged 2 to 5 years. (Source: Don’t Be Rash podcast interview)
- Tapinarof cream (Vtama), an aryl hydrocarbon receptor agonist, is approved for children down to age 2. (Source: Don’t Be Rash podcast interview)
- Ruxolitinib cream (Opzelura), a Janus kinase (JAK) inhibitor, is also approved down to age 2; use is generally limited to treating up to 20% of the body surface area in children. (Source: Don’t Be Rash podcast interview)
- Delgocitinib (Anzupgo), a pan-JAK inhibitor, is currently labeled for chronic hand eczema in adults 18 and older. (Source: Don’t Be Rash podcast interview)
Access and insurance rules still affect which treatments families can actually get. The doctors noted that insurers often require a trial of a topical steroid before approving newer, nonsteroidal creams. That may feel frustrating, but it reflects current coverage practices. (Source: Don’t Be Rash podcast interview)
What this means for families
Topical corticosteroids remain an important option for many rashes, especially for short-term control of flares. Doctors are aware of the concerns patients and parents have about long-term risks, and they aim to use the lowest effective strength for the shortest time needed to control symptoms like itch and sleep disturbance.
If you are worried about side effects or steroid withdrawal, bring those concerns up with your child’s dermatologist. Ask about how much medicine to use, how long to apply it, and whether a nonsteroidal option could be appropriate. A clear plan and a follow-up visit can reduce anxiety and improve safety.
Tracking visible changes
Keeping a simple photo diary of the rash over time can be helpful. Clear photos taken every few days or weeks can show whether a treatment is working or whether a lesion is changing in a way that needs prompt attention. This can also help you explain the situation to your doctor at follow-up. (Source: Don’t Be Rash podcast interview)
When to see a doctor right away
Contact your child’s doctor or dermatologist promptly if you notice sudden changes such as increasing pain, bleeding, signs of infection (pus, warmth, spreading redness), very fast growth of a lesion, or if the rash is causing severe sleep loss or interfering with normal activities. If you are unsure, it is better to ask for advice rather than waiting.
Disclaimer
This article summarizes a conversation from the “Don’t Be Rash” podcast. It is for general information and does not replace medical advice. Treatment decisions should be made together with a trusted dermatologist or pediatrician who knows your child’s medical history.
Sources
- Don’t Be Rash podcast interview with Lawrence Eichenfield, MD, and Andrew C. Krakowski, MD; official podcast of the Society for Pediatric Dermatology. Episode disclosure: supported in part by an unrestricted grant from Arcutis Biotherapeutics. (Source: Don’t Be Rash podcast interview)