Topical Steroids: Potency, Skin Thinning and Withdrawal Evidence

by
Key takeaways
  • UK tubes and boxes now show one of four strengths: "mild", "moderate", "strong" or "very strong". Hydrocortisone is mild, clobetasone moderate, betamethasone strong and clobetasol very strong (Pharmaceutical Journal, June 2024). The US uses seven classes, I to VII, with class I the most potent (Sandoval et al. 2013).
  • In a 2021 umbrella review of 38 systematic reviews, short trials of topical steroids showed no significant difference in skin thinning compared with emollient, with very low event rates. Skin thinning was rare overall, at 8 of 2,068 people (0.4%) treated with steroids, and 7 of those 8 cases involved potent products (Axon et al. 2021).
  • Skin thinning and striae are most linked to potent products, large areas, occlusion, thin skin such as the face and groin, and long continuous use (Stacey & McEleney, American Family Physician 2021). Striae were not studied in the trials we reviewed.
  • Withdrawal-type reactions are the contested part. The MHRA received 267 Yellow Card reports between September 2021 and August 2023. Most described severe reactions after at least six months of moderate-to-very-potent steroids for eczema (Pharmaceutical Journal). The evidence base for a distinct syndrome is weak, and the Feb 2024 joint statement from Eczema UK, the British Association of Dermatologists and the British Dermatological Nursing Group covers the withdrawal debate (Eczema UK).
  • Money trail: the two most rigorous safety reviews we opened were publicly funded by the UK's National Institute for Health and Care Research (NIHR). The authors of one of them declare ties to AbbVie and Eli Lilly, neither of which the review names as a topical steroid maker (Harvey et al. 2023). We did not identify the funders of the older trials of topical steroids themselves, so the manufacturer-funded part of the evidence remains unverified.
  • Proper use, per clinical guidance: the AAFP suggests treating the face, groin and skin folds in short one-to-two-week blocks, and limits super-high-potency products to about three weeks at a time and high or medium products to about 12 weeks (AAFP 2021).
  • Confidence: Moderate that potent steroids on thin skin and long continuous use carry the main atrophy risk. Insufficient for striae. Weak for the existence and frequency of a withdrawal syndrome.

Independent evidence review · Prescription medicine

Topical corticosteroids remain a standard way to treat inflammatory skin disease when the strength, site and duration match the problem. The best independent evidence says short, appropriate courses rarely cause measurable skin thinning, while potent products on the face, groin and skin folds, and long continuous use, carry the main risk. Whether a separate "topical steroid withdrawal" syndrome exists is much less settled. The evidence is weak, and UK regulators and professional bodies describe it as poorly understood. Our confidence is moderate on the atrophy risk factors and low on the withdrawal syndrome.

Best evidence for low rates of skin thinning in short trials and with intermittent use, based on pooled trial data, mostly from short studies
Main risks skin thinning and stretch marks with potent products; withdrawal flares after stopping on the face or genitals; systemic effects at high doses
Key rule match strength to site and duration, and speak to your prescriber before stopping or changing a prescribed steroid

Table of contents

Evidence summary

Claim Evidence Source Funding / conflict Strength
Short or intermittent use rarely causes skin thinning No significant thinning in two 2–4 week trials against emollient (0 of 196 vs 0 of 33; 6 of 109 vs 2 of 50). No thinning in five trials of proactive twice-weekly use (n=993, 16–20 weeks). One episode of skin thinning in the PETITE trial, among 1,213 children on mild or moderate steroids. Axon et al. 2021; Harvey et al. 2023 NIHR-funded; authors are co-applicants on the grant. Harvey et al. declare AbbVie and Eli Lilly ties (neither named as a steroid maker). Moderate
Potent steroids raise the risk of skin thinning Pooled relative risk 4.86 (95% CI 1.06 to 22.28) against calcineurin inhibitors, from four trials. Absolute rates low: 8 of 2,068 (0.4%) on steroids, 0 of 2,060 on comparators. Seven of eight cases involved potent products. Axon et al. 2021 NIHR-funded; no manufacturer funding stated in the overview. Moderate
Risk rises with potency, duration, occlusion and thin skin Clinical overview of expert guidance. Risk rises with larger areas, higher potency, prolonged use, occlusion and thin skin such as the face and groin. Children are more susceptible. Stacey & McEleney 2021 Authors declare no relevant financial affiliations. No separate funding statement. Moderate
Striae (stretch marks) are a risk Striae are listed as a common local effect in clinical guidance. Trials did not report striae; the wet-wrap observational studies reported one case. AAFP 2021; Axon 2021 As above. Insufficient
A distinct withdrawal syndrome exists after long-term potent use A 2015 systematic review (Hajar et al., as summarised by Sheary 2016) is the basis for the syndrome's description. Sheary describes it with moderate-to-high-potency steroids, particularly on the face or genitals, and calls the evidence limited. Sheary 2016 Sheary declares no competing interests. The 2015 review was not opened by us. Weak
MHRA surveillance of severe reactions 267 Yellow Card reports, September 2021 to August 2023, mostly after six months or more of moderate-to-very-potent steroids for eczema. A small number of reactions happened while still using the steroid. Pharmaceutical Journal on MHRA 2024 UK government regulator with no product to sell. Spontaneous reports cannot show how common reactions are. Weak
Strength labelling on products Four UK categories, introduced over the year after the May 2024 statement. Examples: hydrocortisone mild, clobetasone moderate, betamethasone strong, clobetasol very strong. Pharmaceutical Journal 2024; Eczema UK 2025 Regulatory rule. Eczema UK, a patient charity, led the campaign for it. Strong

Independent evidence and credibility scorecard

Independence tiers: 1 = independent, with no identifiable financial stake in the outcome; 2 = indirect ties, such as grant interests or declared sponsorship from a company in a neighbouring field; 3 = interested party, such as a patient charity or advocacy body; 4 = self-interested, meaning funded, sponsored or written by the maker or seller. Credibility runs from A (highest) to D. Every row below is a source we opened. Where a funding statement was not visible, we say so.

Source Who funds it / pays the authors Country Independence tier (1–4) Credibility (A–D) Why it would tell the truth / residual bias
MHRA Yellow Card analysis (as reported by the Pharmaceutical Journal, June 2024) UK government regulator; no product to sell. Funding model not verified. UK 1 A Legal duty to protect patients and accountability to Parliament reward caution. Residual bias: spontaneous reports overcount notable cases and cannot give rates. We read the report via a trade-press summary.
Axon et al., BMJ Open umbrella review (2021) NIHR Programme Grants for Applied Research (UK public funding). Co-applicants on the grant, which funds an eczema self-care intervention. UK 2 B Publicly funded, preregistered (PROSPERO), and reports many low-quality reviews rather than hiding them. Residual bias: the authors are working on eczema self-care, and most included trials lasted only 2–4 weeks.
Harvey et al., Skin Health and Disease systematic review (2023) NIHR Programme Grants (UK public funding). Authors declare ties to AbbVie and Eli Lilly, including sponsorship, an honorarium and an AbbVie-funded podcast. Neither is named as a topical steroid maker. UK 2 B Academic reputation and public funding favour rigorous reporting. Residual bias: declared ties to drug companies make the authors' eczema work commercially linked, though the review does not name a steroid maker. Found no withdrawal data.
Sandoval et al., Journal of Drugs in Dermatology (2013) Funding and conflict statement not shown in the part of the article we opened. US (Wake Forest University School of Medicine) 2 C Academic article that explains the US seven-class system. Residual bias: survey of 105 dermatologists at a 2011 US meeting. Funding unverified.
Stacey & McEleney, American Family Physician (2021) Authors at the Mayo Clinic (Stacey: Mayo Clinic Rochester, Minnesota; McEleney: Mayo Clinic Health System, La Crosse, Wisconsin). Declare no relevant financial affiliations. Publisher revenue model not verified. US 1 B Clinical educators gain credibility from accurate teaching. Residual bias: a summary of guidance, with no evidence grades given and no primary data.
Sheary, Australian Family Physician (2016) No competing interests declared; not commissioned; externally peer reviewed. No funding statement. Australia 1 B GP author with a clinical stake in accurate counselling. Residual bias: relies mostly on one 2015 review; no evidence grade.
Eczema UK, British Association of Dermatologists and British Dermatological Nursing Group joint statement (Feb 2024, via Eczema UK news page) Patient charity with a professional-body co-author. Charity and funding statement not verified; the full PDF was not readable in this check. UK 3 B Professional and patient bodies have a reputational reason to describe the condition accurately. Residual bias: patient advocacy favours recognising TSW. Full text not verified in this check.
Eczema UK labelling campaign report (July 2025) Patient charity; funding not verified. Survey figures are not used in this article. UK 3 C Charity reputation depends on campaign success. Residual bias: campaign framing from the charity itself, and no independent evaluation of the labels.

Convergence and clustering. Two sources with no declared financial ties (Stacey and Sheary) agree with the two NIHR-funded reviews on the main risk factors: potency, duration, the face and genitals, and occlusion. The regulator and the patient charity also agree that severe reactions reported to the MHRA followed long-term use of moderate-to-potent steroids. Their incentives differ, which makes that agreement more useful. Five of the eight sources are UK-based, two are US-based and one is Australian. The verdict on withdrawal therefore reflects a UK lens, and no manufacturer-funded source was among those we could open.

What topical steroids are, and how strength is labelled

Topical corticosteroids are creams, ointments, lotions and foams that reduce skin inflammation. Clinicians use them most often for eczema and plaque psoriasis. The American Family Physician overview groups them into four bands: super-high (class I), high (class II), medium (classes III to V) and low (classes VI and VII). Super-high products are reserved for severe disease and thick skin, such as the palms, soles and psoriatic plaques. Low-potency products suit children, mild or widespread disease, and thin skin such as the face and groin (Stacey & McEleney 2021).

Potency classes in the UK

Since the MHRA's May 2024 statement, UK packs must show one of four strength words: "mild", "moderate", "strong" or "very strong". The Pharmaceutical Journal gives the examples hydrocortisone (mild), clobetasone (moderate), betamethasone (strong) and clobetasol (very strong). The Pharmaceutical Journal says the new labels would be introduced over the next year (Pharmaceutical Journal 2024). We could not open the BNF potency table, so the BNF's own grouping is not confirmed here.

Potency classes in the US

The US uses seven classes, from class 1 (the most potent) to class 7 (the least). Potency is based on vasoconstrictor assays, which measure how strongly a steroid narrows skin blood vessels, and is used as a proxy for activity on the skin (Sandoval et al. 2013). Because the US and UK schemes are built differently, do not map one onto the other. We could not open a product-level US table, so we do not list the US class of individual products.

How they work

Topical steroids reduce the local inflammation that drives eczema and psoriasis. The US classes are based on vasoconstrictor assays, which measure one effect of the steroid on skin blood vessels (Sandoval 2013). That is a measure of strength, not a direct measure of every effect on skin thickness. What is proven: the local anti-inflammatory effect is the reason clinicians use these drugs, and the skin-thinning risk is measured in trials. What is not proven: the exact cellular route by which thin skin and withdrawal-type reactions occur. We did not open a primary mechanism study, so we do not describe one.

What works and what does not

Approach What the evidence shows Verdict
Short courses at the strength matched to the site Clinical guidance treats face, groin and skin folds in one-to-two-week blocks (AAFP 2021). Works (guidance)
Intermittent or proactive twice-weekly use after flares No skin thinning in five trials, n=993, 16–20 weeks (Axon 2021). Long-term data are limited. Mixed
Continuous potent or very potent use on the face, groin or skin folds Highest risk of thinning, striae and withdrawal flares (AAFP 2021; Sheary 2016). Avoid unless a clinician directs
Preventing striae Not studied in the trials we opened (Axon 2021; Harvey 2023). Insufficient
Treating a "withdrawal" reaction with a fixed steroid-stopping plan No controlled trial we opened tests it. Insufficient

Benefits by claim

Do topical steroids treat eczema flares?

They are the standard anti-inflammatory treatment for flares, and the clinical guidance we opened is written around that use. This article is a safety and withdrawal review, so we do not rate their efficacy against other treatments. For that question, see the related guides below.

Can they treat psoriasis plaques?

The AAFP limits super-high-potency products to no more than three weeks at a time (AAFP 2021).

Risks and all side effects

Safety first
Do not stop a prescribed steroid suddenly on your own. Speak to your GP or pharmacist first. Seek urgent help if the skin around a treated area becomes spreading redness, warm, weeping or painful, or if you develop a fever, or if you notice a sudden change in vision or eye pain. Infections can be hidden under steroid creams, and eye problems are a recognised systemic effect (AAFP 2021).

Skin thinning (atrophy)

Skin thinning is the best-documented local risk. In trials of two to four weeks, we found no meaningful difference between steroid and emollient. Against calcineurin inhibitors, the pooled relative risk was 4.86, with a wide confidence interval (1.06 to 22.28). The absolute rate was 0.4%, with seven of eight cases from potent products. Most of the systematic reviews it included were rated low or critically low quality, and most trials lasted only 2–4 weeks, so long-term thinning is not well measured (Axon et al. 2021).

Striae (stretch marks)

Clinical guidance lists striae among the most common adverse effects of topical steroids, alongside atrophy (AAFP 2021). The trials did not report striae. The two wet-wrap observational studies in the umbrella review reported one case (Axon 2021). We could not verify whether striae reverse after stopping, so we do not state a reversibility rate.

Rebound and "withdrawal" reactions

The AAFP reports that stopping prolonged use on the face or genitals can cause redness, scaling, stinging, burning, papules, pustules and oedema. It also says there is no evidence of tachyphylaxis, meaning the steroid does not stop working with use (AAFP 2021). The separate claim of a "topical steroid withdrawal" syndrome rests on weaker evidence. A 2015 systematic review (Hajar et al., summarised by Sheary 2016) describes the syndrome as occurring mainly after long-term use of moderate-to-high-potency steroids, particularly on the face or genitals. Sheary calls the evidence limited. The 2023 review found no data on withdrawal at all (Harvey et al. 2023). The full text of the 2024 joint statement was not reopened in this check (Eczema UK 2024).

Clinician note
The GP author advises treating eczema appropriately, counselling patients at risk and supporting them through withdrawal (Sheary 2016). NHS patients with concerns should raise them at their next appointment with their GP, dermatology team or pharmacist.

Systemic effects

Clinical guidance says the risk of systemic adverse effects in adults is low if doses do not exceed 50 g per week (AAFP 2021). The 2023 review found a small association with type 2 diabetes (odds ratio 1.27, 95% CI 1.19 to 1.36) in one case-control study, rated as very low certainty. Lymphoma findings conflicted (Harvey et al. 2023).

All interactions

We did not open an interactions database. The main interaction we can source is additive systemic exposure: the AAFP's systemic-risk discussion depends on total dose, so steroid tablets, injections or high-dose inhaled steroids used alongside a cream add to that total. Tell your prescriber about every steroid you use (AAFP 2021). We could not verify interaction data for other drugs.

Who should take extra care

  • Children: in the PETITE trial, the one case of skin thinning among 1,213 children occurred on mild or moderate steroids (Axon 2021). Ask the prescriber for the plan for your child.
  • Thin skin and skin folds: the face, groin and skin folds absorb more, so the AAFP limits strength and duration there.
  • Pregnancy and breastfeeding: we did not open a source for this group, so we do not give a risk estimate. Ask a clinician.
  • People on other steroids: the cumulative dose matters (see Interactions).

Doses studied and proper use

The figures below are guidance from the AAFP and the approaches studied in trials. They are not personal instructions. A prescriber should set the plan for each person.

  • Duration: super-high products up to about three weeks at a time; high and medium products up to about 12 weeks, with longer courses using intermittent dosing or a milder product.
  • Face, groin and skin folds: one-to-two-week intervals (same source).
  • Trial approaches: weekend or proactive twice-weekly dosing has been studied in trials, and the umbrella review found no skin thinning in those trials, although they were short (Axon 2021).

Product quality and labelling

The MHRA's labels aim to make strength clear on the pack, tube and leaflet (Eczema UK 2025). We found no product-quality or contamination issues for topical steroids in the sources we opened.

Follow the money: who makes it and who funded the evidence

Who makes and sells it

We could not verify the manufacturers, parent companies or ownership of the main UK, US or European steroid brands from an opened source, so we name none. Readers who want this should check the manufacturer and regulator entries directly.

Who funded the evidence

  • Axon et al. 2021 (umbrella review): NIHR Programme Grants for Applied Research, grant RP-PG-0216-20007. The authors state that the NIHR, the NHS and the Department of Health and Social Care did not necessarily share their views. The authors are co-applicants on the grant, which funds an eczema self-care project (BMJ Open 2021).
  • Harvey et al. 2023: NIHR Programme Grants, grant RP-PG-0216-20007. The funders had no role in the study. Alison Lowe has worked for AbbVie and taken sponsorship from AbbVie and Eli Lilly for events. Sandra Lawton received an honorarium and took part in an AbbVie-funded podcast (Harvey et al. 2023).
  • Stacey & McEleney 2021: no separate funding statement; authors declare no relevant financial affiliations (AAFP 2021).
  • Sheary 2016: no funding; competing interests "None" (Sheary 2016).
  • Sandoval et al. 2013: the funding and conflict statement was not in the part we opened (Sandoval 2013).
  • Manufacturer-funded trials of topical steroids: we did not find a documented manufacturer-funded trial of topical steroid skin thinning among the sources we opened. The older trials in the umbrella review were not opened individually, so this remains unverified.

Patient groups and their positions

  • Eczema UK, BAD and the British Dermatological Nursing Group (22 Feb 2024): the date and co-authors come from search results and the statement's PDF header. The PDF text was not readable in this check, so its wording and any funding statement are not quoted or verified (Eczema UK 2024).
  • Eczema UK's labelling campaign: the charity's news listing reports a 2023 campaign for clear strength labels and a 9 July 2025 article announcing the labels. Its survey figures were not reopened in this check (Eczema UK 2025). This is a charity's own account of its campaign.

Documented integrity events

We found no documented regulatory warning letter, recall or prosecution specific to topical steroid makers in the sources we opened. The MHRA's 2024 Yellow Card analysis is the main documented safety event (Pharmaceutical Journal 2024).

Follow the money

Research funding at a glance

Funding & backersSource & studyClaim & limits

8 sources graded. The counts below are the independence tiers assigned in the scorecard above. They count sources, not funding amounts or evidence quality.

Tier 13Independent
Tier 23Indirect ties
Tier 32Interested party
Tier 40Self-interested

Public funding alone does not prove independence, and commercial funding alone does not prove a claim false. Named funders, countries and relationships are in the scorecard and source notes.

What this means: the strongest safety evidence we opened is publicly funded, and the regulator has no product to sell. The Tier 4 count of zero reflects the sources we could open, not an absence of manufacturer-funded trials. That gap is important, because the trial-based safety data in the umbrella review came from older studies whose funders we could not check.

For wider, evidence-graded context, see these Pure City Research guides:

Frequently asked questions

What do the UK strength labels mean?

Products are now labelled "mild", "moderate", "strong" or "very strong". Hydrocortisone is mild, clobetasone moderate, betamethasone strong and clobetasol very strong (Pharmaceutical Journal 2024).

Do topical steroids thin the skin?

Short and intermittent use showed no measurable thinning in the trials we opened. Potent products carried most of the risk in the rare cases reported. The pooled absolute rate was 0.4% in steroid-treated people, with no cases in comparators (Axon et al. 2021).

Can topical steroids cause stretch marks?

Clinical guidance lists striae as a common local effect (AAFP 2021). The trials did not report striae, so we cannot give a reliable rate.

What is topical steroid withdrawal?

It is a term for skin symptoms that some people describe after stopping long-term steroids. The MHRA describes severe reactions after at least six months of moderate-to-very-potent steroids for eczema (Pharmaceutical Journal 2024). The syndrome is described mainly on the face or genitals after potent use, and the evidence is weak (Sheary 2016; Eczema UK 2024).

Has the MHRA or the NHS recognised topical steroid withdrawal?

The MHRA published its Yellow Card analysis in May 2024, reporting 267 reports between September 2021 and August 2023 (Pharmaceutical Journal 2024). We could not open an NHS-issued statement on the condition, so we cannot confirm one.

Are topical steroids safe for children?

In the PETITE trial, one case of skin thinning occurred among 1,213 children, all on mild or moderate steroids (Axon et al. 2021). Ask the prescriber for the plan for your child.

Should someone stop a steroid cream if they are worried about it?

Do not stop a prescribed steroid suddenly without advice. Speak to your GP, pharmacist or prescriber first, as the safety box above says.

Who pays for the research on topical steroids?

The two most rigorous safety reviews we opened were funded by the UK's NIHR. One set of authors declares ties to AbbVie and Eli Lilly, neither named as a topical steroid maker (Harvey et al. 2023). We could not verify the funders of the older trials of topical steroids.

Sources and funding notes

What we could not verify or open: the BNF topical corticosteroid entry and the NICE appendix returned access errors in an earlier check and were not retried. PubMed returned a rate-limit error, so the 2015 Hajar systematic review and the 2015 Barnes review of skin atrophy are cited only as summarised by other sources and are not counted in the scorecard. The Eczema UK, BAD and BDNG joint statement PDF could not be read in this check, so its wording and funding are not verified. We did not find a separate 2023 MHRA or NHS England statement on withdrawal. We could not verify the funding of Eczema UK, the BAD or the AAFP. We found no documented manufacturer-funded steroid trial in the sources we opened, and we could not check the funders of the older trials. We did not verify manufacturer names or ownership. Search limits also stopped one planned check of NICE CKS guidance on proper use, so the proper-use section relies on the AAFP overview. Checked in this later pass: the BMJ Open umbrella review (Axon et al. 2021, via PMC) and the MHRA Drug Safety Update of 29 May 2024 were opened. The Axon figures (RR 4.86, 95% CI 1.06 to 22.28; 8 of 2,068 steroid cases vs 0 of 2,060; five twice-weekly trials, n=993) match the source. The MHRA figure (267 reports, up to August 2023) matches the Drug Safety Update, which gives no start date; the September 2021 start comes from the Pharmaceutical Journal. Harvey et al. 2023 (via PMC) matches on funding, the AbbVie and Eli Lilly ties, the type 2 diabetes odds ratio and the lack of withdrawal data. Two discrepancies remain noted here: the Axon grant is written RP-PG-0216-20007 in the funding statement and P-PG-0216-20007 in the competing-interests section, and the PETITE count is 1,213 in one section and 2,418 in another. The Eczema UK labelling article is dated 9 July 2025 and carries no funding statement; the 2023 survey article (943 responses) is not used.

  1. Pharmaceutical Journal, "Potency warning labels for topical steroids", 4 June 2024. Trade-press report of the MHRA's 29 May 2024 statement. Funder: Royal Pharmaceutical Society, revenue model not verified.
  2. Eczema UK, "Clearer topical steroid strength labelling introduced", 9 July 2025. Patient-charity account of the labelling campaign. Funder: not verified.
  3. Eczema UK, "Joint statement on topical steroid withdrawal", 22 February 2024. Joint statement by Eczema UK, the British Association of Dermatologists and the British Dermatological Nursing Group. Funding and disclosure statement not verified in this check.
  4. Axon E, et al. "Safety of topical corticosteroids in atopic eczema: an umbrella review." BMJ Open 2021;11(7):e046476. Umbrella review of 38 systematic reviews. Funder: NIHR Programme Grants for Applied Research.
  5. Harvey J, et al. "The long-term safety of topical corticosteroids in atopic dermatitis: a systematic review." Skin Health and Disease 2023;3(5):e268 (PMID 37799373). Systematic review of seven studies. Funder: NIHR Programme Grants; some authors declare AbbVie and Eli Lilly sponsorship.
  6. Stacey SK, McEleney M. "Topical Corticosteroids: Choice and Application." American Family Physician 2021;103(6):337–343. Clinical overview. Authors declare no relevant financial affiliations; no funding statement.
  7. Sheary B. "Topical corticosteroid addiction and withdrawal." Australian Family Physician, June 2016. GP review. Competing interests "None"; no funding statement.
  8. Sandoval LF, Davis SA, Feldman SR. "Dermatologists' knowledge of and preferences regarding topical steroids." Journal of Drugs in Dermatology 2013;12(7):786–789. Survey of 105 US dermatologists and description of the US seven-class system. Funding not shown in the part we opened.

Educational research reviewed 9 October 2026. This article is not medical advice; talk to a qualified clinician or pharmacist before starting, stopping or combining treatments.

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