The Dual Nature of Cortisol Cream
Topical corticosteroids, commonly known as cortisol or hydrocortisone creams, are a cornerstone in dermatology for managing inflammatory skin conditions like eczema and psoriasis [1.4.6]. They work by reducing inflammation, swelling, itching, and redness [1.4.1]. These medications come in various potencies, from mild over-the-counter (OTC) preparations to very potent prescription-only formulas [1.3.4]. While highly effective when used correctly, improper or prolonged use can lead to a range of adverse effects [1.4.1].
Local Side Effects: What Happens to Your Skin?
Overuse of cortisol cream primarily affects the skin where it is applied. These effects develop because corticosteroids can interfere with the normal processes of skin cell growth and maintenance [1.4.2].
Common Local Reactions:
- Skin Atrophy (Thinning): This is one of the most common side effects of overuse [1.3.5]. The skin becomes fragile, translucent, and may bruise easily [1.2.3, 1.3.5]. This is more likely to occur in areas where the skin is already thin, such as the face, groin, and armpits [1.2.3].
- Striae (Stretch Marks): Permanent stretch marks can develop, especially in skin folds or areas like the groin and armpits [1.3.5].
- Telangiectasias (Spider Veins): Small, dilated blood vessels can become visible on the skin's surface [1.3.3].
- Acneiform Eruptions and Perioral Dermatitis: Users may develop acne-like bumps or a persistent red rash around the mouth [1.3.3, 1.2.2].
- Hypopigmentation: The skin may lose color, appearing as lightened patches [1.2.2].
- Increased Hair Growth (Hypertrichosis): Unwanted hair can grow in the treated area [1.2.2].
- Masking or Worsening Infections: Steroids suppress the immune response in the skin, which can mask the signs of a fungal or bacterial infection or allow it to spread more rapidly [1.3.3].
Systemic Side Effects: When It Enters Your Body
Though absorption through the skin is generally low (less than 2% for hydrocortisone), using high-potency steroids over large areas, for extended periods, or under occlusion (like with tight bandages or diapers) increases the amount absorbed into the bloodstream [1.9.1, 1.3.3]. This systemic absorption can lead to serious internal health problems.
Cushing's Syndrome
Iatrogenic Cushing's syndrome is a rare but serious condition caused by prolonged exposure to high levels of cortisol [1.6.1]. While more common with oral steroids, it has been reported from the overuse of potent topical steroids, particularly in children whose higher skin surface-to-body weight ratio increases absorption [1.6.2, 1.6.3].
Symptoms of Cushing's Syndrome include:
- Weight gain, especially in the face ("moon face"), upper back ("buffalo hump"), and torso [1.2.3, 1.4.2].
- High blood pressure [1.4.5].
- High blood sugar (hyperglycemia) [1.4.2].
- Thinning skin, stretch marks, and easy bruising [1.2.3].
- Muscle weakness and fatigue [1.4.5].
- Mood changes, such as irritability or depression [1.2.4].
Adrenal Suppression
When the body is exposed to external corticosteroids for a long time, the adrenal glands may reduce or stop producing their own natural cortisol [1.4.2]. This is known as hypothalamic-pituitary-adrenal (HPA) axis suppression. If the topical steroid is stopped abruptly, the body may not be able to produce enough cortisol on its own, leading to adrenal insufficiency, which can cause fatigue, dizziness, low blood pressure, and body aches [1.4.5, 1.2.4].
| Side Effect Type | Local (On the Skin) | Systemic (Inside the Body) |
|---|---|---|
| Examples | Skin thinning, stretch marks, acne, spider veins, skin color changes, increased hair growth [1.2.2, 1.3.3]. | Cushing's syndrome, adrenal suppression, high blood pressure, high blood sugar, glaucoma [1.4.2, 1.2.4]. |
| Cause | Direct effect of the steroid on skin cells from prolonged application [1.3.3]. | Absorption of the steroid into the bloodstream, affecting the whole body [1.3.2]. |
| Risk Factors | High-potency steroids, use on thin skin (face, groin), long duration of use [1.2.4]. | High-potency steroids, application to large surface areas, long-term use, use of occlusive dressings [1.3.2]. |
Topical Steroid Withdrawal (TSW)
Topical Steroid Withdrawal (TSW), also known as Red Skin Syndrome, is a potential reaction that can occur after stopping the use of topical steroids, particularly after long-term, frequent use of moderate-to-high potency creams [1.5.3, 1.5.6]. It is characterized by skin symptoms that are often more severe than the original condition being treated [1.5.4].
Key features of TSW include:
- Intense skin redness (erythema) that can spread beyond the original treatment area [1.5.4].
- A severe burning or stinging sensation [1.5.3].
- Intense itching, peeling, or oozing open sores [1.5.4].
- Symptoms appearing days to weeks after discontinuing the steroid [1.5.5].
TSW is considered a rare reaction, and it can be difficult to distinguish from a flare-up of the underlying skin condition. A key indicator of TSW is often a burning sensation rather than just itching, and redness that spreads [1.5.4].
Safe Usage and Conclusion
To avoid these adverse effects, it is crucial to use cortisol creams exactly as directed by a healthcare provider or as stated on the OTC label [1.7.2]. This includes using the lowest effective potency for the shortest possible duration, applying a thin layer only to affected areas, and avoiding use on broken skin or sensitive areas like the face and genitals unless specifically instructed [1.7.1, 1.7.3]. If symptoms do not improve within the recommended timeframe (usually 7 days for OTC products), a doctor should be consulted [1.7.2].
In conclusion, while cortisol creams are valuable medications, using too much poses significant risks ranging from cosmetic skin changes to severe systemic conditions. Responsible use under medical guidance is essential to harness their benefits while minimizing harm.
For more information on the appropriate use of these medications, visit the NHS website on hydrocortisone for skin.
