Topical Steroid Use and Children: Reasonable Fear or a Phobia?

I’m a pediatric dermatologist who specializes in the care of severe inflammatory diseases such as psoriasis and atopic dermatitis. These conditions can impair the overall health, development, and quality of life of affected children.

The time-proven gold standard (first-line treatment) for these conditions is topical corticosteroids. Occasionally, when I prescribe a topical steroid for a child, I sense genuine fear in the parent. Because parents are responsible for a child’s treatment program, their fear can create major obstacles to compliance. Sadly, it’s ultimately the child who suffers. I’ve given a lot of thought as to why parents are afraid of topical steroids for their children and share my experiences and advice in this post.

Every patient, parent, and family brings their own beliefs, values, and perceptions to the visit. I respect this and try to create a management plan that is safe, effective, and within the comfort level of the family. The fear of topical steroids may derive from a combination of myths, misperceptions, and experiences with medical professionals who lacked the knowledge to explain or prescribe topical steroids correctly. It’s important to address these fears and knowledge gaps among patients and healthcare providers. The ability for a child to thrive, free from the burden of itchy, rashy skin, depends on their access to proper treatment for their inflammatory skin diseases and their comfort using the treatments.

Here are a few main facts about topical steroids. Topical steroids:

  • are a gold standard treatment for most inflammatory skin conditions.
  • have been around for many decades, at least 30 years.
  • work by decreasing inflammation and itch.
  • are not the type of steroids athletes use to build muscle.
  • when used correctly, are not going to “build up” in the body and have negative consequences.

Topical steroids come in seven different potency classes. Class 1 is very potent while class 7 is the weakest. Topical steroids of varying potencies are used safely when prescribed by a doctor who knows how to use these medicines correctly. All dermatologists know and understand these classes. Outside of dermatology, physicians are not often trained regarding skin disease or the medications used to treat it. Unless a physician has learned about these potency classes and other aspects of treatment, they may under-treat, over-treat, or not treat the skin disease at all. Choice of topical steroids depends on the diagnosis and the body part involved. I don’t prescribe the same steroid class for an arm or leg as I would for the face or diaper area. Problems arise when a medical professional lacks the complete knowledge base to properly prescribe the correct potency for different sites on the body.

Steroid prescription is a nuanced science. It’s based on the type of rash, severity, body location, and age of the child. Which steroid, where it’s to be used, and how long it’s used need to be constantly assessed by a physician to avoid under- and over-treatment. Sometimes I’m not the first doctor a child will see for their skin condition, and I have to address the fears parents have about side effects of steroids. Side effects are rare but can develop when steroids are prescribed or used incorrectly. However, I believe steroid fear derives more from the misperceptions about the risks of adverse effects rather than actual observed side effects. Physicians untrained in steroid use may overstate the risks to parents, thus creating fear and hesitation for families about using them. Furthermore, the internet can be your best friend and your worst enemy. Information is available about skin disease and its treatment; however, the majority of internet postings are not regulated. That is, anyone can post anything, with or without the knowledge, education, or training on which to base the information. It’s natural for parents, grandparents, and friends to share their stories and fears in person and online. Consequently, the fear spreads. Confusion with athlete steroid abuse, misinformation, fear, and misperception all contribute to a parent’s hesitancy to use steroids on their child.

This is the message I want you to understand: topical steroids are one of the most effective medications used to treat skin disease, and they have been used effectively for over three decades. There can be risks if these medicines are used incorrectly; however, their safety can be assured when a dermatologist or physician who is experienced and knowledgeable with their use does the prescribing. Ironically, not using a topical steroid when prescribed appropriately can create more problems than using it, as skin disease and itch can lead to attention deficits in school, poor sleep, and disruption of the entire family dynamic.

I have found that one of parents’ biggest concerns with steroid use is growth suppression. Ironically, growth suppression and failure to thrive can happen if a child with severe skin disease is under-treated. Eczema in particular is a long-term chronic skin condition that, if left untreated, can create high metabolic demands on the body, leading to poor weight gain and growth. In other words, a child’s body can’t keep up with the demands their condition puts on them. I’ve witnessed entire family dynamic changes because of an under-treated child. A child who has dermatitis or psoriasis is itchy and uncomfortable. Parents invite the child to co-sleep so the parent can scratch them to sleep. The parents don’t sleep well, and the child is uncomfortable and can’t concentrate on school or relax and play; no one is happy.

When used incorrectly, topical steroids do pose some risk of problematic side effects. These include atrophy or thinning of the skin, stretch marks, hypopigmentation (skin turns lighter), acne-like rashes and dermatitis. Infants are most at risk because they have a high body surface-to-mass ratio. These risks increase when high-potency agents are used on large surfaces of skin. However, these risks are rare. In fact, a recent research study whose results were published in the journal Pediatric Dermatology showed that long-term use of topical corticosteroids to treat children with eczema doesn't cause any major negative side effects. During the study, "all of the children were assessed for signs of corticosteroid-related side effects" and the researchers found that "there were no differences between the children receiving the medication and those in the control group." This type of information is very reassuring, but unfortunately, scientific-based information is not often available to laypeople and thus information is largely based on myths, fears, and urban legends.

If you’re a parent of a child who has a skin condition, I offer my practical advice:

  1. Care of inflammatory skin disease requires more than just topical steroids. I use a plan that includes treating the inflammation, treating the itch, looking for and treating any triggering factors in the child or the environment, and educating the parents regarding the rationale for each part of the treatment plan.
  2. Understand that your child’s treatment regimen will likely include a topical steroid among other treatments. When used appropriately, topical steroids are safe and effective, and can improve your child’s condition and quality of life.
  3. Understand which steroid is prescribed, for what part of the body, and for how long. The steroid medication should be used as long as the rash is there but tapered down to a less potent agent or moisturizer as the rash is improving.
  4. Ask for written instructions regarding the details of the treatment plan. With an education on steroid use and written instructions by a physician knowledgeable in the intricacies of topical steroids you should be empowered to make the right choices for your child’s health. Remember, topical steroids are not the only treatment available but often are required as a part of the overall regimen. Educate yourself with facts, rather than myths, and look forward to improved quality of life for your child, and ultimately, the whole family.
Published on 07/13/2011 | Last updated on 10/18/2018