Are topical steroids considered systemic? Unpacking the absorption and risks

October 10, 2025 •

4 min read

While generally intended for local action, topical steroids can be absorbed through the skin, and even small doses of potent formulations can produce systemic side effects, particularly in vulnerable populations like children. Understanding whether are topical steroids considered systemic is crucial for patient safety and proper medication use.

Quick Summary

Topical steroids can be absorbed into the bloodstream, posing a systemic risk that increases with potency, application area, and duration. Potential adverse effects, such as adrenal gland suppression, are manageable with proper usage and careful monitoring by a healthcare professional.

Key Points

Systemic Absorption Risk: Topical steroids can be absorbed into the bloodstream, meaning they are not exclusively localized medications.
Absorption Factors: Risk of systemic effects increases with higher potency steroids, larger application areas, and longer treatment durations.
Vulnerable Populations: Children and individuals with thin or inflamed skin are at a higher risk for systemic absorption due to their physiology.
HPA Axis Suppression: The most serious systemic risk is the suppression of the adrenal glands, which can lead to adrenal insufficiency if the medication is stopped abruptly.
Proper Use is Key: To minimize risks, use the lowest effective potency, limit treatment duration, and avoid sensitive areas and occlusion unless medically advised.
Topical Steroid Withdrawal: Abruptly stopping potent steroids after long-term use can trigger a rebound flare or withdrawal reaction, also known as 'Red Skin Syndrome'.

For years, topical corticosteroids have been a frontline treatment for various inflammatory skin conditions like eczema and psoriasis. Their primary advantage lies in delivering medication directly to the affected area, minimizing the systemic exposure associated with oral steroids. However, the assumption that topical application eliminates all systemic risk is a misconception. The skin, as the body's largest organ, is not an impenetrable barrier, and systemic absorption of these medications is a well-documented phenomenon. The degree to which a topical steroid acts systemically depends on multiple factors, and understanding these is essential for both patients and healthcare providers.

Understanding Systemic Absorption

Pharmacology classifies medications based on their route of administration, and topical drugs are typically understood to have localized effects. However, absorption into the systemic circulation is always possible and is influenced by the drug's properties and the condition of the skin. Once absorbed, the corticosteroid can circulate in the bloodstream and exert effects on internal organs, particularly the hypothalamic-pituitary-adrenal (HPA) axis.

Factors Influencing Systemic Absorption

The amount of a topical steroid that enters the bloodstream is not static and is determined by several critical factors:

Potency of the steroid: Higher-potency corticosteroids, such as clobetasol, are more readily absorbed and carry a greater risk of systemic effects than lower-potency options like hydrocortisone.
Area of application: Applying steroids over a large body surface area, such as in widespread eczema or psoriasis, dramatically increases the total amount of drug absorbed. Pediatric patients are particularly vulnerable due to a higher skin surface area-to-body weight ratio.
Duration of treatment: Prolonged or chronic use, especially with potent steroids, increases the total dose absorbed over time, raising the risk of systemic side effects.
Occlusion: Covering the treated area with an occlusive dressing (e.g., plastic wrap or a diaper) significantly enhances absorption by increasing skin hydration and temperature. This practice can increase absorption by up to 10 times.
Skin barrier condition: Damaged or inflamed skin, a characteristic of many dermatological conditions, has an impaired barrier function. This allows for enhanced percutaneous absorption compared to healthy, intact skin.
Anatomical site: The skin's thickness varies across the body. Absorption is higher in areas with thinner skin, such as the face, eyelids, and genitals, and lower on thick skin like the palms and soles.

Local vs. Systemic Side Effects

Using topical steroids can result in both localized and systemic adverse effects. The table below provides a comparison of these two categories, highlighting the differences in their manifestation and severity.


Feature	Local Side Effects	Systemic Side Effects
Mechanism	Occur directly at the application site due to local tissue effects.	Result from the drug's absorption into the bloodstream, affecting internal systems.
Onset	Can appear relatively quickly with prolonged or high-potency use.	Generally develop with long-term, high-dose, or large-area application.
Examples	Skin atrophy (thinning), striae (stretch marks), telangiectasias (spider veins), rosacea, and perioral dermatitis.	HPA axis suppression, iatrogenic Cushing's syndrome, growth retardation in children, hyperglycemia, and ocular issues like glaucoma.
Prevalence	More common, especially with improper or extended use.	Rare when topical steroids are used appropriately, but risk increases with misuse.

The Risks of Systemic Absorption

The most significant systemic risk associated with topical steroids is the suppression of the HPA axis. The body's adrenal glands naturally produce cortisol. When steroids are absorbed systemically, the body receives a signal to reduce its own cortisol production. If the external steroid is abruptly discontinued, the adrenal glands may not be able to resume sufficient cortisol production, leading to adrenal insufficiency. This can cause symptoms like fatigue, weakness, low blood pressure, and appetite loss.

Another rare but serious risk is the development of iatrogenic Cushing's syndrome, characterized by a puffy face, central obesity, and striae. This condition occurs from excessive, prolonged systemic exposure. In children, systemic absorption is a particular concern as it can lead to growth retardation, a side effect monitored carefully by pediatricians.

Minimizing Systemic Effects and Using Topical Steroids Safely

To mitigate the risk of systemic absorption and its associated side effects, patients must follow their healthcare provider's instructions carefully. The following practices are recommended for the safe and effective use of topical steroids:

Use the lowest effective potency: Start with the mildest steroid that will control the skin condition. Potent steroids should be reserved for more severe cases and shorter durations.
Limit treatment duration: Acute flares should be treated for the shortest time possible, typically a few weeks. For long-term management of chronic conditions, intermittent therapy (e.g., using it on weekends only) can reduce cumulative exposure.
Avoid large application areas: Do not use potent steroids over extensive body surface areas. If a large area requires treatment, a lower-potency steroid is often a safer choice.
Be cautious with occlusion: Avoid occlusive dressings unless specifically instructed by a doctor, especially with potent steroids. Never use occlusive dressings on infants without medical supervision.
Avoid sensitive areas: Exercise extreme caution when applying steroids to the face, groin, and underarms, as these areas have higher absorption rates. Always use the lowest potency possible for these sensitive sites.
Monitor pediatric use: Children, especially infants, are at a higher risk of systemic absorption. Treatment should be closely monitored by a healthcare professional.

Conclusion

In summary, while topical steroids are designed for local effects, the answer to the question are topical steroids considered systemic is a qualified 'yes.' Though the risk of systemic side effects is rare with appropriate use, it is a significant consideration, particularly with prolonged use, high potency, large application areas, or compromised skin. Patients must use these medications as prescribed and be aware of the factors that can increase absorption. By following recommended safety protocols, the therapeutic benefits of topical steroids can be maximized while minimizing the risk of adverse outcomes, ensuring safe and effective treatment for inflammatory skin diseases. For additional information on side effects, consulting authoritative sources like the National Eczema Society is recommended.

Frequently Asked Questions

Yes, absorption is significantly higher in areas with thinner skin, like the face and genitals. For these sensitive areas, only low-potency steroids should be used for short durations under a doctor's guidance to minimize systemic absorption.

HPA axis suppression is the reduction of the body's natural cortisol production due to prolonged systemic absorption of steroids. It is a risk because if the medication is stopped suddenly, the body may not produce enough cortisol, potentially causing adrenal insufficiency.

Signs of excessive systemic absorption can be subtle but may include weight gain, fluid retention, high blood pressure, and fatigue. In children, a slowdown in growth may be a sign. Regular follow-ups with your doctor are important for monitoring.

Not necessarily. A potent steroid can clear a condition quickly, reducing the overall treatment time and cumulative steroid exposure. The danger lies in using high-potency steroids incorrectly, such as over large areas or for prolonged periods.

There are several steroid-sparing alternatives available, including topical calcineurin inhibitors (like tacrolimus or pimecrolimus) and newer PDE4 inhibitors (like crisaborole). These can be used for maintenance therapy to reduce reliance on corticosteroids.

Yes, using an occlusive dressing, such as plastic wrap, can increase the absorption of topical steroids by several times. This practice should only be done under a doctor's supervision for specific conditions and durations.

To minimize risk, apply a thin layer only to the affected area, as prescribed. For large areas, use a lower potency steroid. The 'fingertip unit' method can help ensure the correct amount is used.