The use of steroids in dermatological disease has been traditionally described as a double edged sword. Used sparingly and for the right indications and time period, topical and systemic steroids offer the patient dramatic benefits. On the other hand, used indiscriminately, incorrectly or without medical supervision, steroids can cause more damage than good and lead to an unending cycle of partial remission and relapse [1]. The rules of steroid use and abuse apply equally in the field of trichology and in the management of hair and scalp disorders. This makes it particularly crucial for dermatologists and trichologists to consider utilities of topical steroids against their side effects, and to make informed careful decision regarding their use in each patient based on clinical criteria including age, area involved, indication and chronicity of the hair or scalp disorder.

The use of topical steroids in hair and scalp disorders can be broadly classified into four categories:

In each of these the astute clinician may use topical steroids to help the patient, while the less informed dermatologist or physician could misuse topical steroids in a strength or duration that harms the patient.

Similarly the misuse or abuse of topical steroids in this range of disorders can be classified into the following categories:

Effects and side effects of topical steroids on the skin have been dealt with exhaustively [2] in other chapters of this compendium. A comprehensive review of hair and scalp disorders and their treatment is also not the aim of this chapter. For purposes of brevity and clarity, the role of topical steroids and the potential for use and abuse will be discussed using an example of relatively common conditions under each category.

Topical steroids used for hair and scalp disorders are usually lotions, gels or shampoos and less commonly ointments, creams, foams or sprays [3].

Ointments are better for lubrication and occlusion than other preparations and improve steroid absorption. But, they should at best be avoided on hairy areas as they may result in folliculitis or maceration.

Creams are cosmetically attractive, but are usually less potent than ointment. Creams are ideally chosen for the scalp margin in conditions like psoriasis when they extend beyond the hairline.

Lotion and gels are the least greasy. There are preferred for hairy areas because they penetrate easily and leave little residue. Gels dry fast and can be applied on the scalp or other hairy areas as they do not result in matting. Foams/mousses and shampoo are effective vehicles for delivering steroid to the scalp but are costly.

Intralesional steroids are often used on the scalp for a local delivery of topical steroid. Steroid shampoos have also been used for conditions including seborrheic dermatitis and scalp psoriasis. Like other body parts topical corticosteroids are the therapeutic backbone for many dermatoses of the scalp and they decrease erythema, scaling and pruritus significantly. Medicated shampoos are a more convenient choice for patients who need topical administration of corticosteroids for the scalp conditions [3]. Tar shampoos are used to treat scalp psoriasis. This preparation is effective for the maintenance of remission in patients who respond to therapy. Antifungal shampoos are useful in seborrheic dermatitis. Fluocinolone acetonide, 0.01% in shampoo formulation has been approved for the treatment of seborrheic dermatitis. Even superpotent corticosteroid shampoo (clobetasol propionate 0.05%) is permitted in the USA for once-daily treatment of scalp psoriasis. It was demonstrated in a pilot study in 2007 that clobetasol propionate shampoo improved the signs and symptoms of seborrheic dermatitis. It is based on these findings we can conclude that high-potency corticosteroid shampoos are considered as an effective therapeutic option for the treatment of scalp dermatoses. The question is not only whether they work or not; the more important question is whether they can be used indiscriminately. There are controversies regarding the efficacy of drug delivery, the relatively short contact time, the potential of over-the-counter misuse and the risk of long-term use by the less informed patient. These need to be addressed and steroid formulations for the scalp have to be chosen considering the hairiness of the anatomical location, the cosmetic importance and visibility of the scalp and hair and the potency and indication for therapy. Other factors like inflammation of the scalp, simultaneous use of oil or gel and frequency of head bath may affect the effectiveness and side effects of these molecules on the scalp.

Alopecia areata is an example of a hair disorder in which steroids have a significant role, are indicated in select cases and can have a measurable therapeutic benefit. The use of topical steroids in alopecia areata ranges from intralesional injections to potent topical formulations in localized areas.

Intralesional corticosteroids is the treatment of choice of Alopecia Areata since 1958. Different studies have reported success rates of 60–75%. Triamcinolone acetonide (TAC) is the molecule usually preferred. It is to be ideally injected into the deep dermis or upper subcutaneous tissue using a 0.5-inch long 30-gauge needle at multiple sites, 1 cm apart and 0.1 ml into each site, once in 4–6 weeks. Various concentrations (2.5–10 mg/ml) of TAC have been used, but 5–10 mg/ml is preferred for scalp and 2.5 mg/ml for eyebrows and face. The maximum dose per sitting should not exceed 20 mg [4]. Regrowth of hair should be visible in roughly 4 weeks. Discontinuation of intralesional corticosteroids is recommended if there is no significant improvement by the end of 6 months. A subset of patients with decreased expression of thioredoxin reductase 1, an enzyme that activates the glucocorticoid receptor in the outer root sheath of alopecia areata, are resistant to steroid therapy. Atrophy can take place, this can be minimized by avoiding superficial injections, minimizing the volume and spacing the sites of injection. The atrophy, if at all, is usually transient and reversible. Hypopigmentation, telangiectasia and rarely anaphylaxis are reported. Cataract and raised intraocular pressure can occur if intralesional corticosteroids are used near the eyebrows. Hypopigmentation and skin atrophy can occur either when topical corticosteroids are applied/injected topically or locally. Venkatesan and Fangman demonstrated that melanocytes are structurally intact in steroid-induced hypopigmentation. This proposes that topical steroids may disturb melanocyte function more than the structure. Triamcinolone may cause depigmentation as because of its larger size, the greater tendency to aggregate and higher density. Hence for lesions close to the skin surface, particularly in hyperpigmented patient triamcinolone should better be avoided, and topical steroids with smaller particles and less tendency to aggregate may be used [1].

More recently Thappa et al. attempted to classify alopecia areata based on age and percentage of scalp surface involved [5]. Based on this classification topical steroids were used in some patients and intralesional steroids or oral mini-pulse was chosen for others.