Topical Corticosteroids by Structural Class

Topical Corticosteroids by Potency

(I—MOST POTENT, VII—LEAST POTENT)

Brand	Generic Name	Size	Fluorinated?
I - up to 600X more potent than hydrocortisone
Temovate cr, ot 0.05%	Clobetasol propionate	15, 30, 45 g	Y
Diprolene ot, cr 0.05%	Betamethasone dipropionate	15, 50 g	Y
Psorcon ot 0.05%	Diflorasone diacetate	15, 30, 60 g	Y
Ultravate cr, ot 0.05%	Halobetasol dipropionate	15, 45 g	Y

II - 100-150X more potent than hydrocortisone
Cyclocort ot 0.1%	Amcinonide	15, 30, 60 g	Y
Diprosone ot 0.05%	Betamethasone dipropionate------	15, 50 g	Y
Elocon ot 0.1%	Mometasone furoate	15, 45 g	N
Florone ot 0.05%	Diflorasone diacetate	15, 30, 60 g	Y
Halog cr, ot, sl 0.1%	Halcinonide	cr, ot: 15, 30, 60, 240 g	Y
		sl: 20, 60 mL
Lidex cr, gl, ot, sl 0.05%------	Fluocinonide	15, 30, 60, 120 g	Y
		sl: 20, 60 mL
Maxiflor ot 0.05%	Diflorasone diacetate	15, 30, 60 g	Y
Maxivate cr, ot 0.05%	Betamethasone dipropionate	15, 45 g	Y
Topicort cr, ot 0.25%	Desoximetasone	15, 60 g	Y
Topicort gl 0.05%	Desoximetasone	15, 60 g	Y

III - 2-25X more potent than hydrocortisone
Aristocort A ot 0.1%	Triamcinolone acetonide	15, 60 g	Y
Cutivate ot 0.005%	Fluticasone propionate	15, 30, 60 g	Y
Cyclocort cr, lt 0.1%	Amcinonide	cr: 15, 30, 60 g	Y
		lt: 20, 60 mL
Diprosone cr 0.05%	Betamethasone dipropionate	15, 45 g	Y
Florone cr 0.05%	Diflorasone diacetate	15, 30, 60 g	Y
Lidex-E cr 0.05%	Fluocinonide	15, 30, 60, 120 g	Y
Maxiflor cr 0.05%	Diflorasone diacetate	15, 30, 60 g	Y
Maxivate lt 0.05%	Betamethasone dipropionate	60 mL	Y
Valisone ot 0.1%	Betamethasone valerate	14, 45 g	Y
ot 0.1%	Halcinonide

IV
Aristocort ot 0.1%	Triamcinolone acetonide	15, 60 g	Y
Cordran ot 0.05%	Flurandrenolide	15, 30, 60, 225 g	Y
Elocon cr, lt 0.1%	Mometasone furoate	cr: 15, 45 g	N
		lt: 30, 60 mL
Kenalog cr, ot 0.1%	Triamcinolone acetonide	15, 60, 80, 240 g	Y
Kenalog aerosol 0.2%	Triamcinolone acetonide	63 mL	Y
Dermatop cr, ot 0.1%	Prednicarbate	15, 60 g	N
Synalar ot 0.025%	Fluocinolone acetonide	20, 60 g	Y
Topicort LP cr 0.05%	Desoximetasone	15, 60 g	Y
Westcort ot 0.2%	Hydrocortisone valerate	ot: 15, 45, 60 g	N
Cloderm cr 0.1%	Clocortolone pivalate	45, 90 g	Y

V
Cordran cr 0.05%	Flurandrenolide	15, 30, 60 g	Y
Cutivate cr 0.05%	Fluticasone propionate	15, 30, 60 g	Y
cr 0.025%	Fluticasone acetonide		Y
Kenalog lt 0.1%	Triamcinolone acetonide	15, 60 mL	Y
Kenalog ot 0.025%	Triamcinolone acetonide	15, 60, 80, 240 g	Y
Locoid cr, ot 0.1%	Hydrocortisone butyrate	15, 45 g	N
Synalar cr 0.025%	Fluocinolone acetonide	15, 60 g	Y
Tridesilon ot 0.05%	Desonide	15, 60 g	N
Valisone cr 0.1%	Betamethasone valerate	cr: 15, 45, 110, 430 g	Y
Westcort cr 0.2%	Hydrocortisone valerate	15, 45, 60, 120 g	N

VI
Aclovate cr, ot 0.05%	Alclometasone dipropionate	15, 45 g	N
Aristocort cr 0.1%	Triamcinolone acetonide	15, 60 g	Y
Kenalog cr, lt 0.025%	Triamcinolone acetonide	cr: 15, 60, 80	Y
		lt: 60 mL
Locoid sl 0.1%	Hydrocortisone butyrate	20, 60 mL	N
Locorten cr 0.03%	Flumetasone pivalate	15, 60 g	Y
Synalar cr, sl, oil 0.01%	Fluocinolone acetonide	cr: 15, 45, 60 g	Y
		sl: 20, 60 mL
Tridesilon cr 0.05%	Desonide	15, 60 g	N
Valisone lt 0.1%	Betamethasone valerate	20, 60 mL	Y

VII
Hytone cr, ot, lt 1%	Hydrocortisone acetate or HCl	cr, ot: 30 g	N
		lt: 120 mL
Hytone cr, ot, lt 2.5%	Hydrocortisone acetate or HCl	cr, ot: 30 g	N
		lt: 60 mL

Cr, cream; gl, gel; lt, lotion; ot, ointment; sl, solution.

German Classification System
german steroid classification.png

Notes

Fluticasone and mometasone have long half-lives and may be best choice for QD dosing
Prolonged use of potent fluorinated topical steroids increase risk for skin atrophy, telangiectasias, acne, particularly on face, axilla, inguinal areas
A gram of topical cream or ointment should cover a 10 × 10-cm area
A 30-60 g tube will cover the entire body of an adult once
FDA approval of topical steroids for children:

Topical Corticosteroids by Structural Class

Structural class	Class A: Hydrocortisone type	Class B: Triamcinolone acetonide type	Class C: Betamethasone type	Class D1: Betamethasone dipropionate type	Class D2: Methylprednisolone aceponate type
Cross-reactions	Cross-reacts with D2	Budesonide specifically cross-reacts with D2			Cross-reacts with class A and budesonide
Patch Test Substance	Tixocortol-21-pivalate	Budesonide Triamcinolone acetonide		Clobetasol-17-propionate	Hydrocortisone- 17-butyrate
Class 1 Superpotent				Betamethasone dipropionate (Diprolene 0.05% G, O, L) Clobetasol propionate (Clobex Cormax, Dermovate, Temovate C, O, G, S Olux foam 0.05%) Diflorasone diacetate (Psorcon 0.05% O)
Class 2 Potent		Amcinonide (Cyclocort 0.1% O, L, C) Budesonide (Naricort 0.025% C) Fluocinonide (Lidex 0.05% C, O, G, S) Halcinonide (Halog 0.1% C, O, S)	Desoximetasone (Topicort 0.25% C, 0.05% G)	Betamethasone dipropionate (Diprosone, Maxivate 0.05% O, Diprolene AF 0.05% C) Betamethasone valerate (Betnovate 0.1%) Diflorasone diacetate (Florone, Maxiflor 0.05%)
Class 3 Upper mid-strength		Amcinonide (Cyclocort 0.1% L) Fluocinonide (Lidex 0.05%) Triamcinolone acetonide (Aristocort Kenalog 0.1% C, O) Triamcinolone diacetate (Amcort, Aristocort 0.1% C, O)		Betamethasone dipropionate (Diprosone, Maxivate 0.05% C) Betamethasone valerate (Betatrex, Valisone 0.1%, O, Luxiq foam 0.12%) Clobetasone butyrate (Eumovate 0.05%) Diflorasone diacetate (Florone, Maxiflor 0.05% C) Fluticasone propionate (Cutivate 0.005% O) Mometasone furoate (Elocon 0.1% O)
Class 4 Mid-strength		Amcinonide (Cyclocort 0.1% C) Fluocinolone acetonide (Derma-Smoothe 0.01%, Synalar 0.025% O) Halcinonide (Halog 0.025%, C) Triamcinolone acetonide (Aristocort, Kenalog, Triacet 0.1%, O) Triamcinolone diacetate (Amcort, Aristocort 0.1%, O)	Clocortolone pivalate (Cloderm 0.1% C) Desoximetasone (Topicort 0.05% emollient cream)	Clobetasone butyrate (Eumovate 0.05%) Mometasone furoate (Elocon 0.1% C, L)	Hydrocortisone valerate (Westcort 0.2% O)
Class 5 Lower mid-strength		Desonide (DesOwen, Tridesilon 0.05% O) Fluocinolone acetonide (Derma-Smoothe, Synalar 0.025% C) Triamcinolone acetonide (Aristocort, Kenalog 0.1% C, Kenalog 0.025% O, L) Triamcinolone diacetate (Amcort, Aristocort 0.1% C)		Betamethasone dipropionate (Diprosone, Maxivate 0.05% L) Betamethasone valerate (Betatrex, Valisone C, L) Fluticasone propionate (Cutivate 0.05% C)	Hydrocortisone buteprate (Pandel 0.1% C, O, S) Hydrocortisone butyrate (Locoid 0.1% C, O, S) Hydrocortisone valerate (Westcort 0.2% C) Prednicarbate (Dermatop 0.1% C)
Class 6 Mild		Desonide (DesOwen, Tridesilon 0.05% C) Fluocinolone acetonide (Derma-Smoothe, Synalar 0.01% C, Sol) Triamcinolone acetonide (Aristocort, Kenalog 0.025% C) Triamcinolone diacetate (Amcort, Aristocort 0.025% C)		Alclometasone dipropionate (Aclovate 0.05% C, O) Betamethasone valerate (Valisone 0.1% C)
Class 7 Least potent	Hydrocortisone (Bactine, Caldecort, Corticaine, Delacort, Dermolate, Hytone, Prepcort, Resicort) Hydrocortisone acetate (Cortaid, Cortef Feminine or Rectal Itch Cream, Gynecort, Lanacort, Wellcortin) Tixocortol pivalate (Pivalone)

Topical Calcineurin Inhibitors (TCIs)

Pimecrolimus 1% (Elidel) cream BID, 30, 60, 100 g
Tacrolimus 0.03% (Protopic) oint BID, 30, 60 g
Tacrolimus 0.1% (Protopic) oint BID, 30, 60, 100 g

TCI Malignancy Risk

AAAAI/ACAAI Joint Task Force: “None of the information provided for the cases of lymphoma associated with the use of topical pimecrolimus or tacrolimus in AD indicate or suggest a causal relationship.”
FDA guidance regarding risk of malignancy with topical calcineurin inhibitors:
- Use only as 2nd line in patients unresponsive/intolerant of other treatments
- Avoid in children <2 years old; clinical studies have found higher rates of URIs in children <2 who were treated with pimecrolimus (Elidel).
- Use for short periods of time and with minimum amount necessary; avoid continuous use.
- Avoid in immunocompromised patients

Topical Anti-MRSA

Bactroban (mupirocin 2%) topical ointment, TID up to 12 days for impetigo, 15, 22, 30g
- Bactroban nasal (mupirocin calcium 2%) ointment indicated for treatment of nasal MRSA carriers, 0.5 g intranasal BID x 5 days, supplied as 10-pack of 1 g tubes
Altabax (retapamulin 1%) topical ointment, BID x 5 days for impetigo, 5, 10, 15g