There is no evidence of safe and effective use of topical corticosteroids in pregnant mothers. Therefore, they should be used only if clearly needed. Long term use and large applications of topical corticosteroids may cause birth defects in the unborn. It is not known whether topical corticosteroids enter breast milk. Therefore, caution must be exercised before using it in nursing mothers. Topical corticosteroids should not be applied to the breasts of nursing mothers unless the mothers instructed to do so by the physician.
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.