Topical Steroid Toolbox for Pediatrics
Author: Renee Howard MD
Date: October 2024
Posted: August 2025
PALS: Potency, Age of patient, Location & Severity of rash
POTENCY
Classified strongest (I) to weakest (VII)
Potent: Class I and II
Severe/acute rashes or short term “rescue” for flares
Avoid/proceed with caution, taper, don’t refill without seeing
Class I: augmented betamethasone dipropionate, clobetasol, halobetasol
> 5 years on hands, feet, scalp, or acute rashes (i.e. poison oak)
Class II: betamethasone dipropionate, fluocinonide, mometasone,
> 3 years on hands, feet, scalp, or acute rashes (i.e. poison oak) rescue only, 1-2 weeks then taper
Midpotency: Class III, IV, V
Your go-tos for moderate rashes on trunk and extremities
III Triamcinolone acetonide .5%> 3, on body. Only comes in 30g tube
IV Triamcinolone acetonide .1%: >1, body. Available in 80g tube, 1 lb jar
V Fluocinolone acetonide . 01% oil. Triamcinolone .025% for body, comes in 80g tubes and 1 lb jars
Low potency: Class VI, VII for mild rashes
VI Desonide or Alclometasone: all ages, ok on face, groin, diaper area. Comes in small tubes
VII Hydrocortisone 1 or 2.5%: any age or location. Comes in small tubes or 1 lb jar
Quantities
“Fingertip units” can help parents understand how much topical steroid they should use.
Also description can help:
For steroid “Very thin layer like butter on toast”
For emollient “Thick layer like frosting on a cake or cream cheese on a bagel”
Summary of Steroid Strength
Steroid potency |
Class and Examples |
Role in treatment of pediatric skin disease |
Low | VII Hydrocortisone 1%, 2.5% VI Desonide, alclometasone | Face and diaper area rescue & taper Body for taper |
Medium | V Triamcinolone .025%, Fluocinolone acetonide .01%
IV Triamcinolone 0.1%
III Triamcinolone 0.5% | Body rescue and taper |
High | II Fluocinonide, mometasone, Betamethasone dipropionate
I Clobetasol, halobetasol, augmented betamethasone dipropionate | Hands, feet, scalp rescue Acute on body e.g. poison oak, insect bite reactions
Do not use < 5 years of age Short term/rescue only > 5 years of age |
AGE OF PATIENT
< 3 months old:
Face, neck, groin: hydrocortisone 1, 2.5%
Body: Triamcinolone .025% for short term “rescue” then taper
3months to 2 years:
Face, neck, groin: hydrocortisone 1, 2.5%; if worse desonide for rescue
Body: Triamcinolone .025%; Triamcinolone acetonide .1% for short term “rescue” (1-2 weeks) then taper
2 years to 5 years:
Face, neck, groin: hydrocortisone 1, 2.5%; if worse alclometasone or desonide
Body: Triamcinolone acetonide .025% or .1%, if worse Triamcinolone .5% then taper. Can start to use nonsteroids pimecrolimus, tacrolimus, crisaborole for taper and maintenance. Remember they can sting.
7 years to 21 years:
Face, neck, groin: hydrocortisone 1, 2.5%; if worse use alclometasone, desonide
Body: Triamcinolone acetonide .1%, if worse Triamcinolone .5% or fluocinonide, focal hands/feet/scalp or short term can use Class I or II then taper. Max 1-2 weeks for potent steroids.
Can use nonsteroids pimecrolimus, tacrolimus, crisaborole for taper and maintenance
Can use nonsteroid ruxolitinib if > 12 years for maintenance in sensitive areas
LOCATION, LOCATION, LOCATION
Note: * are not covered by MediCal, can require prior authorization
1. Face, anterior neck, axillae, groin: skin is thin
a. Mild: hydrocortisone 1% or 2.5%
b. Moderate: alclometasone or desonide (*some Medical)
c. Taper/chronic: pimecrolimus cream* , tacrolimus ointment*, or crisaborole ointment*
2. Posterior neck, trunk, extremities: skin is thick
a. Mild: triamcinolone .025% ointment
b. Moderate: triamcinolone .1% ointment
c. Severe: triamcinolone .5% ointment
d. Rescue: fluocinonide .05% ointment
3. Hands and feet: skin is very thick
a. Mild: triamcinolone .1% ointment
b. Moderate: same or .5% ointment
c. Severe: fluocinonide .05% ointment
d. Rescue: fluocinonide .05%, clobetasol ointment (*some cover)
4. Scalp: skin is thick and hard to get to
a. Mild: hydrocortisone 1 or 2.5% lotion
b. Moderate: triamcinolone .1% lotion
c. Severe: fluocinonide .05% gel, solution* or clobetasol lotion*
VEHICLES
Vehicle | Where and when to use | Notes |
Lotion | Hairy areas, skin folds | Can feel unpleasantly wet |
Gel | Hairy areas, skin folds Good for bug bite reactions | Dries quickly Not many available |
Cream | Weepy, wet rashes like poison oak, facial rashes | Older kids and adults like better than oint Many types available |
Ointment | Go to for dry rashes like atopic dermatitis and psoriasis | Older kids don’t like the sticky feeling Many types available |
Oil | Mild diffuse atopic dermatitis Scalp | Fluocinonide acetonide only agent in oil, not covered by MediCal, expensive |
Sleuthing Stubborn Eczema
Noncompliance/steroid phobia/fear/anxiety: open, non-judgmental communication. “Sometimes parents become concerned about using topical steroids on their children after they read about scary side effects on social media. What questions can I answer about the safety of your child’s prescription creams?”
Explain the need to calm the skin short term (in 1-2 weeks) so it can heal, then plan to taper down from initial “rescue” regimen to maintenance regimen safe for longer term.
Recognize need to use nonsteroid alternative for taper and maintenance.
-Infection most common cause of flares; consider culture, treat
-Identify hidden triggers: irritants like detergent in soaps, scented laundry or skin care products, crawling on wool rugs
-Infants: food allergy
- 3 years and older: environmental allergens like dust and grass, or allergic contact dermatitis to topical preparations. May require referral to allergist for prick testing, dermatologist for patch testing.
-Teens: compliance falls off, parents stop supervising skin care. Long hot steamy showers. Irritating scented skin care products, promoted by so-called skinfluencers on social media
Nonsteroid anti-inflammatory agents
Agent | How supplied | Indications | Role | Side effects Other issues |
Pimecrolimus | cream 1% | Atopic dermatitis > 2 years of age | Face, axilla, groin for maintenance Eyelid flare + maintenance | Can sting May require prior auth $$ |
Tacrolimus ointment
| ointment .03% or 0.1% | Atopic dermatitis > 2 years to 18 .03%, 16 or older use 0.1% | Same as above | Stings, burns May require prior auth $$$ |
Crisaborole | ointment 2% | Atopic dermatitis > 2 years of age | Anywhere, for maintenance | Stings, burns $$$$ Prior auth, tried and failed above |
Ruxolitinib
| cream 1% | Vitiligo, atopic dermatitis > 12 years of age
| Anywhere, for maintenance | $$$$ Prior auth Prior auth, tried and failed above |
Contraindications
Pimecrolimus and tacrolimus: active cutaneous herpes or other viral infection, pregnant or breastfeeding, Netherton’s syndrome, cutaneous T cell lymphoma or systemic lymphoma, immunocompromised, radiation therapy or extensive UV exposure.
Crisaborole: none
Ruxolitinib: none
Language to use for prior authorization for nonsteroids
“Patient has tried and failed low potency topical steroid ***. Because rash is located on the eyelid/face/axilla/groin, nonsteroid alternative needed as chronic use of topical steroids in this location is contraindicated.”
For children > 2 years of age, some plans do cover pimecrolimus cream and tacrolimus ointment .0.03%; 0.1% for patients 16 years and older. They are first line before crisaborole or ruxolitinib.
Disclaimer: This document serves as a guide only, not decision support and is not continuously reviewed. Drug dosing and pathway specifics should always be reviewed by prescribers with continuously reviewed sources
References
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Topical steroid withdrawal and steroid phobia
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*This report describes cases of children off topical steroids for months with recurrence of rash that the author attributes to the topical steroid use months prior-a classic correlation/causation error.
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