Topical steroid allergy and dependence

(1) When a topical corticosteroid fails to control a skin condition, the first explanations are usually a wrong diagnosis or inadequate drug potency; however, allergy or dependence should also be considered. (2) Contact dermatitis due to a topical corticosteroid is difficult to diagnose as the symptoms are often mixed with those of the underlying skin disease. Allergy to topical corticosteroids can mimic acute eczema or localised acute swelling. The most commonly affected areas are the legs, hands and face. (3) Risk factors include long term, frequent application of topical steroids by patients with leg ulcers, stasis dermatitis, atopic dermatitis or contact dermatitis (especially on the hands). The diagnostic performance of skin tests is controversial. (4) Several studies and other lines of evidence point to rare allergic cross-reactions to topical corticosteroids, undermining the usefulness of switching to a second topical corticosteroid. (5) Sometimes, especially when skin tests are negative, the problem seems to be dependence to the topical corticosteroid rather than allergy. (6) In practice, stopping the steroid treatment completely is sometimes the best solution, although this may prove difficult.