Topical corticosteroid use — SCE Dermatology MCQ

Correct answer: C — Mild steroid for eyelids and potent steroid for hand flare

The correct answer is C, mild steroid for eyelids and potent steroid for hand flare. Topical corticosteroid potency must be matched to both anatomical site and disease severity: the eyelid skin is extremely thin with the highest percutaneous absorption of any body site, so only a mild agent (for example hydrocortisone 1 percent) should be used there to avoid atrophy, periorbital telangiectasia and glaucoma or cataract risk with prolonged use. The dorsal hand has thick, lichenified skin from chronic scratching, which is far less steroid-responsive and absorbs poorly, so a potent steroid used for a short defined course is needed to induce remission before stepping down. This site-specific, severity-matched approach reflects the standard stepped potency principle in current UK eczema management and directly addresses the patient's steroid phobia by demonstrating safe, targeted use rather than blanket avoidance or blanket high potency. Why the other options are wrong: A, Very potent steroid to eyelids and hand: very potent steroids on eyelid skin risk rapid atrophy, striae and ocular complications such as glaucoma from periocular absorption, and are not justified for a thin inflamed plaque. C, Mild steroid to both sites for months: a mild steroid will not penetrate lichenified hand eczema adequately, prolonging the flare and reinforcing the patient's belief that treatment does not work, and prolonged mild use everywhere ignores the need for site-specific stepping up. D, Topical antibiotic-steroid combination to both sites: the stem explicitly states there is no infection, so a combination antimicrobial-steroid preparation is unnecessary and risks antimicrobial resistance and contact sensitisation. E, Systemic prednisolone as first-line treatment: oral corticosteroids are not first-line for localised atopic eczema and are reserved for severe, extensive or refractory disease under specialist guidance, with risks of rebound flare on withdrawal. Key point: topical corticosteroid potency should be chosen according to both the thinness of the skin site and the severity/lichenification of the eczema, using mild steroids on eyelids and potent short courses on thickened, lichenified skin such as the hands.

Reference: NICE Clinical Knowledge Summaries, Corticosteroids - topical (skin), nose, and eyes, last revised June 2022, https://cks.nice.org.uk/topics/corticosteroids-topical-skin-nose-eyes/