Topical steroids are first line pharmacologic therapy. In deciding on a topical steroid regimen several factors must be taken into consideration including: (1) age of patient, (2) body site to be treated, (3) steroid vehicle (., lotion, cream, ointment), and (4) risk factors for topical steroid side effects. 37 Infants have a greater body surface area to mass ratio and thinner skin, increasing the risks of systemic absorption and cutaneous atrophy respectively. An over-the-counter (OTC) 1% hydrocortisone ointment or cream may be the best initial therapy in this age group. Topical steroids are generally prescribed twice daily to affected areas but there is no evidence that this provides additional benefit over once daily use. 37, 38 As dermatitis improves topical steroids should be gradually weaned in favor of emollients. In infants unresponsive to OTC products, a class VI agent such as aclometasone % or hydrocortisone % cream or ointment is an appropriate step up and only in unusual circumstances should anything more potent be used. In children and adults a similar strategy may be employed utilizing more potent agents as necessary. For facial dermatitis ( Figure ) even in adults, every effort should be made to utilize a class VI or weaker agent; however, trunk and extremity dermatitis may require a class IV or V agent such as triamcinolone % ointment. Certain regional variations such as the thick palms and soles or lichenified plaques in nickel allergic contact dermatitis ( Figure ) may require more potent class I, II, or III agents to achieve benefit.
Steroid induced glaucoma may develop after application of steroid preparations applied to the skin of the eyelids. This elevation occurs most frequently with chronic use, such as in patients with atopic dermatitis. Close IOP monitoring of these patients is essential and consideration of a non-steroidal topical medication, such as tacrolimus and pimecrolimus, should be considered as an alternative. Elevation in intraocular pressure has also been noted with application of steroids on skin that was not periocular, either from ocular contamination or systemic absorption.  Patients should be advised to wash their hands after applying dermatologic steroids or to use gloves.