Topical corticosteroids (TCS) are readily available in Australia. Over the counter TCS are available in low and moderate potency forms: hydrocortisone 0.5% 30 g, hydrocortisone 1% 30 g and clobetasone butyrate 0.05% 30 g can be purchased without a script from Australian pharmacies.

TCS are frequently prescribed in Australia. In 2015–2016, 2.4% of general practitioner (GP) consults resulted in a prescription for TCS [1], and in a survey of 258 GPs, 66% reported prescribing TCS 1–5 times daily [2]. Most skin-related presentations are likely to be managed by GPs as while 17.4% of GP consults dealt with a skin complaint in 2015–2016, dermatological referrals were provided in only 0.8 per 100 patient encounters [1].

Potent TCS are commonly prescribed in all age groups in Australia. In a 2014 survey of 198 Australian dermatologists, nearly all reported prescribing potent or superpotent TCS to treat paediatric eczema [3]. In an analysis of the 2008 Department of Veterans Affairs health claims, 73% of TCS scripts were for potent TCS [4].

TCS prescribing recommendations vary slightly in Australia. An Australasian consensus statement on TCS in paediatric patients published in 2015 advised using TCS once or twice daily to all the inflamed skin until eczema is cleared [5]; and in a survey of GPs, 47% reported instructing patients to this effect [2]. In Australian Prescriber, the authors suggested the more specific recommendation of limiting TCS use to the face for 2 weeks and to the body for 3–4 weeks [6]. Similar explicit advice is provided by some GPs, with 41% reporting instructing patients to use TCS for a maximum of 2 weeks or less [2]. Australian Therapeutic Guidelines advise [7]: ‘Do not give precise guidance about the number of days the topical corticosteroid can be used. Use the drug until the skin is completely clear (usually 7–14 days, but fewer in mild cases or more in severe cases or on thick skin)’. They also recommend: ‘If the skin does not clear or the dermatitis continually recurs soon after clearance, refer for expert advice’.

Much of the discussion regarding TCS and eczema in Australia is focused on the safety of TCS [5] and TCS phobia [8], and so it is not surprising that Australian guidelines address under-treatment with TCS. No guidelines mention TCS overuse. The Australian Therapeutic Guidelines advise: ‘Reassure patients and parents that the benefits of topical corticosteroids outweigh the harms and they should not be afraid to use them’. They also state: ‘If topical corticosteroid therapy fails, the most common reason is underuse due to misplaced fear about safety’. This emphasis on the problem of TCS under-treatment may be partially due to the death in Australia of a malnourished child from septicaemia secondary to infected atopic dermatitis, where the parents elected homoeopathic remedies over conventional medical management [9].