Expert Consensus: Time for a Change in the Way We Advise Our Patients to Use Topical Corticosteroids

Anthony Bewley


The British Journal of Dermatology. 2008;158(5):917-920. 

In This Article

What are the Barriers to Success With Topical Treatment?

It is much less easy to advise patients how to use a topical skin preparation correctly than it is to explain how to take a tablet by mouth. Often the advice given is inadequate, with the result that the patient is left confused – and, in the case of topical corticosteroids, even anxious – about using the preparations that have been prescribed.

Few attempts have been made to rationalize advice on applying topical therapy. The method that has gained widest acceptance has been the fingertip unit (FTU). It is over 15 years since this simple tool was devised to help doctors and patients obtain a better understanding of the amount of topical products, such as corticosteroids, they should use on different parts of the body.[3] The FTU – the amount of cream or ointment expressed from a 5-mm diameter nozzle, applied from the distal skin-crease to the tip of the patient's index finger (Figure 1) – can be used to calculate how much product is needed to cover affected areas, such as the face and neck, and hence the quantity which should be prescribed. It has the advantage of automatically correcting for body size: thus one FTU (approximately 500 mg) is sufficient to cover two adult palms and three FTUs should be sufficient for a single application to one arm irrespective of the size of the individual being treated.[1]

A fingertip unit.

The FTU is used in some factsheets, such as that produced by Patient UK, to help patients understand how much cream to apply ( Table 1 ).[4] For example, one FTU is recommended for treating the fingers, palm and back of an adult hand, or an entire arm and hand of a 3–6-month-old baby.

However, use of FTUs by physicians and awareness of them by patients is not widespread. Making patients aware of the FTU system will not solve the problem entirely, unless it is clearly explained. It is worth spending time to ensure that patients – or parents of children prescribed topical agents – are confident in using it.

Undertreatment is undoubtedly a common cause of low efficacy.[5] However, even when patients understand how much product they should apply, concerns about drug safety, particularly of corticosteroids, often result in a failure to adhere to recommended dosages. In a U.K. survey of 200 dermatology outpatients with atopic eczema, 72.5% said they were worried about using topical corticosteroids on their own or their child's skin, and 24% admitted to having been noncompliant with treatment because of these concerns.[2] In addition, 9.5% of patients were worried that systemic absorption could affect growth and development. This is despite the fact that the most commonly used topical corticosteroid was hydrocortisone – a mild steroid. Furthermore, nearly a third of patients who used this preparation erroneously classified it as either strong or very strong or alternatively did not know its potency.

Further evidence of the rather poor patient understanding of the topical steroids that they are prescribed comes from another U.K. survey to determine the level of use and knowledge of commonly prescribed agents among parents or carers of 100 children attending paediatric outpatient clinics.[6] Eighty-six per cent of patients were using low-potency topical corticosteroids, but only 41% of those who had used hydrocortisone were aware that it was of low potency, and 44% graded it as moderately potent. Of 65 who had used the moderately potent 0.05% clobetasone butyrate, 29% graded it as potent and 12% as weak. Of the 50 patients who had used 0.1% betamethasone valerate, 42% did not grade it as potent.

In the public perception, corticosteroids carry similar risks, regardless of their potency, and typical warnings to restrict the amount of topical preparation that is used, i.e. 'apply thinly' or 'apply sparingly' serve only to reinforce these concerns.


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