What is the Steroid Cream Ladder?

by

Dr Zaid Ismail

The steroid cream ladder refers to the stepped approach to prescribing topical corticosteroids based on their potency and appropriate use for different body areas and conditions. It’s a useful framework for GPs to safely escalate or de-escalate treatment in managing inflammatory skin conditions like eczema or psoriasis.

Classification of Potency

According to the British National Formulary (BNF), topical steroids are grouped into four categories:

  1. Mild
    • Hydrocortisone 0.5–1%
    • Suitable for face, flexures, infants
  2. Moderate
    • Clobetasone butyrate 0.05% (e.g. Eumovate)
    • Suitable for trunk and limbs in adults
  3. Potent
    • Betamethasone valerate 0.1% (e.g. Betnovate)
    • Mometasone furoate 0.1% (e.g. Elocon)
    • For short-term use on thicker skin areas
  4. Very Potent
    • Clobetasol propionate 0.05% (e.g. Dermovate)
    • Reserved for resistant or lichenified areas; avoid face

Principles of Use

  • Use the lowest effective potency for the shortest duration
  • Apply once or twice daily, depending on product
  • Avoid prolonged use on thin skin (face, genitals)
  • Step up or down the ladder depending on response and site

Fingertip Unit (FTU) Guidance

  • One FTU ≈ 0.5g, covers two adult palms
  • Helps prevent over- or under-use

Indications for Potency

Site/ConditionPreferred Potency
Face/genitalsMild
Trunk/limbs (mild)Moderate
Lichenified plaquesPotent or Very Potent
ChildrenMild to Moderate

When to Review or Refer

  • No improvement after 1–2 weeks
  • Recurrent flares needing potent steroids
  • Suspicion of steroid-induced skin damage
  • Consider dermatology input for complex or refractory cases

References

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