Choosing a topical steroid in children depends on type of dermatosis, site, frequency of application, vehicle, duration, and other drug-related factors. Mildly potent topical corticosteroids are used on the face, eyelids, flexures, and diaper region. Moderately to highly potent topical corticosteroids are used in conditions like atopic dermatitis, psoriasis, vitiligo, lichen planus, and lichen planus hypertrophicus (Figs. 10.1, 10.2, 10.3, 10.4, 10.5, and 10.6). Conditions like lichen planus hypertrophicus, lichenified lesions, and prurigo nodularis may require application of topical corticosteroid under occlusion for better absorption, but there is a need to be cautious against side effects, whereas if it is applied on diaper area, it may cause excessive absorption due to occlusive effect leading to adverse effects [4]. Cushing’s syndrome has been reported because of use of excess topical corticosteroid in diaper region [5].

Topical corticosteroid plays a vital role in management of atopic dermatitis. The fingertip unit (FTU) can give a guide to the use of topical corticosteroid especially when treating atopic dermatitis. Parents can be counselled about the FTU to prevent excess usage and adverse effects [6]. Ointment base is used for dry and lichenified lesion, cream base is used for inflamed lesion, and lotion base is appropriate in hairy areas. Ideally topical corticosteroids should be used for localized skin lesions for shorter periods in children. Topical corticosteroids have been used as intermittent therapy, weekend therapy, or intermittent hot spot therapy to prevent tachyphylaxis, and these types of therapy have been in use mainly for atopic dermatitis [7].

Although topical corticosteroids are useful in many dermatoses, it has been extensively abused and misused leading to various local and systemic side effects. Children are more susceptible to local and systemic side effects even with small amount of potent steroids. Adverse effect depends on factors like chemical structure, potency of drug, vehicle, active metabolites, age of child, site of application, quantity of drug, frequency, duration, density of hair follicles, hydration, occlusion, type of dermatosis, or any hepatic or renal involvement [2]. Common local side effects include atrophy, post-inflammatory hypopigmentation or hyperpigmentation, striae, telangiectasias, hemorrhage, purpura, ulceration, hypertrichosis, aggravation of fungal infections, herpes simplex, recurrent furunculosis, tachyphylaxis, and steroid dependency (Figs. 10.7, 10.8, 10.9, 10.10, 10.11, 10.12, and 10.13). In the adolescent age group, topical corticosteroid has been misused for treatment of acne vulgaris leading to steroid acne, perioral dermatitis, rosacea, facial erythema, and folliculitis [8]. Prolonged use of topical corticosteroid of low potency, which is commonly used in children, can give rise to allergic contact dermatitis due to instability of the drug. Systemic side effects seen in children are HPA axis suppression, iatrogenic Cushing’s syndrome, growth retardation, avascular necrosis of the femoral head, glaucoma due to use of topical steroid on the eyelid, and severe disseminated cytomegalovirus infection resulting in death in infants [9]. Iatrogenic Cushing’s syndrome has been documented more in children than in adults. In children it was seen more in infancy group and seen with dermatosis like diaper dermatitis, psoriasis, non-bullous ichthyosiform erythroderma, and xerosis of the skin [10]. Studies have shown that the most common topical corticosteroid associated with iatrogenic Cushing’s syndrome in children is clobetasol propionate 0.05% and betamethasone, and the mean duration of application which was from 1 to 17 months with recovery period of HPA axis was 3.49 ± 2.92 months [11]. Slowing of linear growth has been reported in an infant treated with topical corticosteroid [9, 12]. Disseminated cytomegalovirus infection has been reported in two infants after using clobetasol propionate. [5].