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Are Low-Potency Corticosteroids Safe for Use as Hair Loss Treatments?

Corticosteroids are a class of steroid hormones that have emerged as a treatment against, in particular, alopecia areata and scarring alopecia. These compounds, synthesized to mimic the activity of cortisol, a hormone produced by the adrenal glands, exhibit potent anti-inflammatory and immunosuppressive properties. This makes them effective in treating hair loss conditions where inflammation or an autoimmune response plays a critical role.

However, long-term corticosteroid use is not without potential drawbacks. When overused (or used for too long), topical corticosteroids are causally linked to hormonal changes, alterations to skin pigmentation, the creation of spider veins, and even skin thinning. Some adverse effects can be permanent – with the risk of irreversibility increasing alongside the dose and duration of use. Without usage breaks and/or careful dosing guidelines, long-term users of topical corticosteroids can inadvertently disfigure their skin.

In the last two years, we’ve observed a concerning trend in the hair loss industry: big-brand telehealth companies now add low-dose corticosteroids – i.e., 1% hydrocortisone and 0.01% fluocinolone – to their prescription hair growth topicals. They’re also recommending patients apply corticosteroids to their scalps up to twice daily, forever.
These corticosteroids undoubtedly help lower scalp inflammation and may offset skin irritation from ingredients like tretinoin (retinoic acid) – which is often paired with hair growth drugs, such as minoxidil, to enhance drug activation and penetration.

But is there any evidence that twice-daily use of topical corticosteroids – applied daily, forever, and with no pulse dosing or dosing breaks – is safe? Or are these telehealth companies exposing their patients to unknown risks, gambling with their health, and selling them into short-term hair gains without considering the long-term consequences?

This article will delve into the efficacy and long-term safety of corticosteroids – particularly as a therapy for hair loss disorders. We’ll explore corticosteroids and their therapeutic role in treating hair loss. We’ll also explore considerations for dosing and duration. This is particularly important for people who might be currently using topical corticosteroids on their scalps and who don’t understand the risks they might be exposing themselves to 5-10 years into the future.

What Role Do Corticosteroids Play in Treating Alopecia?

In the context of alopecia, corticosteroids reduce inflammation and suppress the immune system’s activity around hair follicles. This action can halt the progression of hair loss and, in many cases, stimulate hair regrowth. The application of corticosteroids in hair loss treatment can vary; they can be administered topically, injected directly into the scalp, or taken orally. 

Within the class of corticosteroids are:

Glucocorticoids: such as cortisol and cortisone, influence carbohydrate, fat, and protein metabolism.[1]Macfarlane, D.P., Forbes, S., Walker, B.R. (2008). Glucocorticoids and fatty acid metabolism in humans: fuelling fat redistribution in the metabolic syndrome. Journal of Endocrinology. 197(2), … Continue reading They are anti-inflammatory, immunosuppressive, and vasoconstrictive (narrow blood vessels). Their anti-inflammatory effects occur through inhibiting inflammatory mediators and stimulating anti-inflammatory mediators. Their immunosuppressive effects occur through direct action on immune cells.[2]Coutinho, A.E., Chapman, K.E. (2011). The anti-inflammatory and immunosuppressive effects of glucocorticoids, recent developments, and mechanistic insights. Molecular and Cellular Endocrinology. … Continue reading 

Mineralocorticoids: such as aldosterone, regulate electrolyte and water balance. They modulate ion transport in the renal tubules of the kidneys.[3]Yang, J., Young, M.J. (2009). The mineralocorticoid receptor and its coregulators. Journal of Molecular Endocrinology. 43(2), 53-64. Available at: https://doi.org/10.1677/JME-09-0031

How is the Potency of a Corticosteroid Decided?

There are seven potency classifications for corticosteroids, which range from Class I – super potent corticosteroids to Class VII – least potent corticosteroids.[4]Gabros, S., Nessel, T.A., Zito, P.M. (2023) Topical Corticosteroids. In: StatPearls [Internet]. Treasure Island (FL):  StatPearls Publishing. Available from: … Continue reading This is based on several factors, including its chemical structure, formulation, and the ability of the drug to cause vasoconstriction in the skin, which is often assessed through vasoconstrictor assays.[5]Stoughton, R.B. (1992). The vasoconstrictor assay in bioequivalence testing: practical concerns and recent developments. International Journal of Dermatology. Available at: … Continue reading These assays measure the degree of skin blanching (induction of longer-than-normal skin paleness) induced by the corticosteroid. 

What are the Benefits of Corticosteroids in Treating Alopecia?

Corticosteroids are particularly beneficial in treating alopecia areata and scarring alopecias because they modulate inflammatory and immune response pathways. High potency, medium potency, and low potency have all shown some efficacy in treating alopecia, with the highest efficacy observed with high-potency corticosteroids under occlusion.[6]Alsantali, A. (2011). Alopecia areata: a new treatment plan. Clinical Cosmetic and Investigational Dermatology. 4, 107-115. Available at: https://doi.org/10.2147/CCID.S22767 

However, it should be noted that their maximum usage durations depend on the potency of the corticosteroid. Super potent corticosteroids have a maximum duration of 3 weeks, high and medium potency have a maximum duration of 12 weeks, and low potency have no specified limit.[7]Stacey, S.K., Mceleney, M. (2021). Topical Corticosteroids: Choice and Application. American Family Physician. 103(6). 337-343. Available at: … Continue reading Continuing to use corticosteroids after these time points may increase the risk of experiencing adverse effects.

What Risks Are Associated with Corticosteroid Use?

Topical corticosteroids can lead to both skin-related (cutaneous) and whole-body (systemic) side effects, with risk increasing with a larger area of application and higher potency of the drug.[8]Stacey, S.K., Mceleney, M. (2021). Topical Corticosteroids: Choice and Application. American Family Physician. 103(6). 337-343. Available at: … Continue reading 

Some common skin-related effects can include:

  • Skin thinning
  • Stretch marks
  • Spider veins
  • Easy bruising and purpura
  • Delayed wound healing 
  • Hyper or hypopigmentation
  • Acne and rosacea like eruptions
  • Hypertrichosis (increased hair growth)
  • Infections or aggravation of existing infections

Long-term use may lead to whole-body (systemic) effects. These can include:

  • Hypothalamus-pituitary-adrenal activity suppression (characterized by weakened immunity, anxiety, midday fatigue, difficulty sleeping, depression, and aching joints, amongst others)
  • Cushingoid appearance (moon face, acne, and thin, easily bruised skin, amongst others)
  • Unwanted facial skin hair in women (hirsutism) 
  • Impotence
  • Menstrual irregularities
  • Peptic ulcer disease
  • Cataracts
  • Increased intraocular pressure/glaucoma
  • Myopathy
  • Osteoporosis
  • Vertebral compression fractures​

Some patients may also experience a rebound phenomenon – although this is rare in low-potency corticosteroids.

One case study shows a patient who experienced worsening rebound after being treated with first 0.5%, then 1% of hydrocortisone, and again after a 5-day course of clobetasol butyrate and then hydrocortisone.[9]MEDSAFE, (2013). Steroid Rebound – A Topical Issue. MEDSAFE. Available at: https://www.medsafe.govt.nz/profs/PUArticles/June2013Steroid.htm (Accessed: 12 January 2023) It only resolved 3.5 months after stopping all steroid treatments.

However, a retrospective study of 300 patients found that patients who had received hydrocortisone 0.75% and precipitated sulfur 0.5% lotion for up to 15 years for common dermatological conditions of the face showed no evidence of rebound phenomenon, steroid acne, and perioral dermatitis.[10]Harlan, S.L. (2008). Steroid acne and rebound phenomenon. Journal of Drugs in Dermatology. 7(6). 547-550. Available at: PMID:18561585

What are the Long-Term Effects and Safety Profiles of Low Potency Corticosteroids?

There is no specified limit on the duration of use of low-potency corticosteroids. But how safe are they really? Are there any long-term studies showing that these steroids are safe to use long-term?

We’ve collated the longest studies available for several low-potency corticosteroids to help us determine this.

Corticosteroid Study: alopecia Study: other indication Safety profile (adverse effects?) References
Alclometasone dipropionate 0.05% N/A Applied twice daily for 21 days in 31 patients with psoriasis. A comparative study with clobetasone butyrate cream 0.5%. No reported adverse events. [11]Aggerwal, A., Maddin, S. (1982). Alclometasone Dipropionate in Psoriasis: A Clinical Study. Journal of International Medical Research. 10, 414-418. Available at: … Continue reading       
Desonide 0.05% N/A Twice daily application of either desonide 0.05% hydrogel or desonide 0.05% ointment in 46 patients with mild to moderate atopic dermatitis. The study length was 4 weeks. No reported adverse events. [12]Trookman, N.S., Rizer, R.L. (2011). Randomized Controlled Trial of Desonide Hydrogel 0.05% versus Desonide Ointment 0.05% in the Treatment of Mild-to-moderate Atopic Dermatitis. The Journal of … Continue reading 
Fluocinolone acetonide 0.01% N/A Once daily application for 12 months alongside hydroquinone 4% and tretinoin 0.05% in 228 patients for treating facial melasma. Six cases of telangiectasia (spider veins), 5 mild and 1 moderate. [13]Torok, H.M., Jones, T., Rich, P., Smith, S., Tschen, E. (2005). Hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%: a safe and efficacious 12-month treatment for melasma. Cutis. 75(1), … Continue reading
Hydrocortisone 1% Applied twice daily to areas of hair loss for 2 cycles of 6 weeks on and 6 weeks off for a total of 24 weeks. 42 children with alopecia areata. Hydrocortisone 1% compared to clobetasol propionate 0.05%. Twice daily application of either hydrocortisone 1% or desonide 0.05% for 5 weeks in 113 children with mild-to-moderate atopic dermatitis. 36 children continued the study through to 6 months. Alopecia study: 2 patients in the hydrocortisone group experienced abnormal cortisol levels, which were resolved by the end of the study. One patient showed skin atrophy, which resolved by week 6.  [14]Lenane, P., Macarthur, C., Parkin, C.P., Krafchik, B., DeGroot, J., Khambalia, A., Pope, E. (2014). Clobetasol Propionate, 0.05%, vs. Hydrocortisone, 1% for Alopecia Areata in Children. A Randomized … Continue reading,[15]Jorizzo, J., Levy, M., Lucky, A., Shavin, J., Goldberg, G., Dunlap, F., Hinds, A., Strelka, L., Baker, M., Tuley, M., Czernielewski, J.M. (1995). Multicenter trial for long-term safety and efficacy … Continue reading,[16]Salava, A., Perala, M., Pelkonen, A.S., Remitz, A., Makela. (2022). Safety of tacrolimus 0.03% and 0.1% ointments in young children with atopic dermatitis: a 36-month follow-up study. Clinical and … Continue reading,[17]Sigurgeirsson, B., Boznanski, A., Todd, G., Vertruyen, A., Schuttelaar, M.L.A., Zhu, X., Schauer, U., Qaqundah, P., Poulin, Y., Kristjansson, S., von Berg, A., Nieto, A., Boguniewicz, M., Paller, … Continue reading
Twice daily application of 1. Hydrocortisone 1% or, if needed, hydrocortisone-17-butyrate or 2. 0.03% tacrolimus ointment for a 3-7 day course until clearance was achieved in 152 young children (aged 1-3) with eczema. 3 year follow-up. No side effects were observed for the hydrocortisone group.
Application (not mentioned how often) of either pimecrolimus or 1% hydrocortisone in 2418 infants with atopic dermatitis. The treatment was used at the first signs/symptoms until clearance and initiated at the first signs/symptoms of atopic dermatitis. 5-year follow-up. 1% hydrocortisone was associated with an increased incidence of fever, cough, pharyngitis, viral rash, and lower respiratory tract infection.

A number of the corticosteroids did not have any studies conducted for alopecia areata. Furthermore, several studies did not report any side effects; however, the corticosteroids were only used for 21 – 28 days in these cases. The study using fluocinolone 0.01% was the longest and was used daily for one year, with few side effects, which is promising.[18]Torok, H.M., Jones, T., Rich, P., Smith, S., Tschen, E. (2005). Hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%: a safe and efficacious 12-month treatment for melasma. Cutis. 75(1), … Continue reading However, the researchers claimed that there were no signs of skin atrophy or thinning, but 6 patients did experience telangiectasia (otherwise known as spider veins) – which incidentally is a sign of skin thinning.[19]Mount Sinai, (no date), Telangiectasia. Mount Sinai. Available at: … Continue reading

The only study that used a low-potency corticosteroid to treat alopecia areata was hydrocortisone 1%. In this study, participants applied hydrocortisone 1% or clobetasol propionate 0.05% twice daily to areas of hair loss for 2 cycles of 6 weeks on and 6 weeks off for 24 weeks. During this time, there were few adverse events reported. These were abnormal cortisol levels, which were resolved before the end of the study. Furthermore,  one patient who had extensive alopecia areata showed skin atrophy, which resolved by itself in 6 weeks.[20]Lenane, P., Macarthur, C., Parkin, C.P., Krafchik, B., DeGroot, J., Khambalia, A., Pope, E. (2014). Clobetasol Propionate, 0.05%, vs. Hydrocortisone, 1% for Alopecia Areata in Children. A Randomized … Continue reading 

Furthermore, the only two studies that did include long-term follow-up either used very short pulses of the topical corticosteroid treatment or didn’t mention how often it was used at all.

It is clear from the above table that there is a distinct lack of long-term safety data for the use of corticosteroids in dermatological conditions and hair loss conditions. However, short-term or pulsed use (in the case of hydrocortisone) showed very few, if any, adverse effects.

What Role Do Telehealth Companies Play in The Sale and Use of Corticosteroid Treatments?

Telehealth companies provide a convenient alternative to accessing personalized medication and specialized knowledge that may not be readily available in general practice. Furthermore, you can do this from home, eliminating the need for travel and spending time in waiting rooms. You can buy compounded medications from these companies, including mixtures of finasteride, minoxidil, retinoids, and corticosteroids, amongst other treatments. 

However, it appears that some telehealth companies may not be providing enough information for the typical buyer to determine how often they should be using their products that contain corticosteroids.

Some of these companies are also burying the known safety concerns of low-potency corticosteroids deep within their website navigations, while also not clearly stating these concerns upfront to prospective consumers. This strategy might help to mitigate these companies from legal actions related to non-disclosures, while at the same time, not truly informing their customers of the very real (and uncertain) risks they may face 2, 3, or 5 years into the future while using their products.

Conclusion

Short-term or pulsed use of low-potency corticosteroids might be safe and effective for hair loss conditions such as alopecia areata. However, the long-term safety of these treatments is less clear, with a distinct lack of extensive, long-term studies. The risks of long-term corticosteroid use are well-documented, which underscores the importance of careful monitoring and following medical guidance when using these treatments. While telehealth companies offer convenience and access to a range of hair loss treatments, including those containing corticosteroids, there is a gap in providing comprehensive safety information and use guidelines that align with the currently available data. This lack of information raises concerns about the potential for overuse or misuse of these products.

References

References
1 Macfarlane, D.P., Forbes, S., Walker, B.R. (2008). Glucocorticoids and fatty acid metabolism in humans: fuelling fat redistribution in the metabolic syndrome. Journal of Endocrinology. 197(2), 189-204. Available at: https://doi.org/10.1677/JOE-08-0054
2 Coutinho, A.E., Chapman, K.E. (2011). The anti-inflammatory and immunosuppressive effects of glucocorticoids, recent developments, and mechanistic insights. Molecular and Cellular Endocrinology. 335(1), 2-13.  Available at: https://doi.org/10.1016/j.mce.2010.04.005
3 Yang, J., Young, M.J. (2009). The mineralocorticoid receptor and its coregulators. Journal of Molecular Endocrinology. 43(2), 53-64. Available at: https://doi.org/10.1677/JME-09-0031
4 Gabros, S., Nessel, T.A., Zito, P.M. (2023) Topical Corticosteroids. In: StatPearls [Internet]. Treasure Island (FL):  StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532940
5 Stoughton, R.B. (1992). The vasoconstrictor assay in bioequivalence testing: practical concerns and recent developments. International Journal of Dermatology. Available at: https://doi.org/10.1111/j.1365-4362.1992.tb04009.x
6 Alsantali, A. (2011). Alopecia areata: a new treatment plan. Clinical Cosmetic and Investigational Dermatology. 4, 107-115. Available at: https://doi.org/10.2147/CCID.S22767
7, 8 Stacey, S.K., Mceleney, M. (2021). Topical Corticosteroids: Choice and Application. American Family Physician. 103(6). 337-343. Available at: https://www.aafp.org/pubs/afp/issues/2021/0315/p337.html#:~:text=Triamcinolone%20acetonide%200,Ointment%2C%20cream%2C%20lotion%2C%20gel%2C%20foam (Accessed: 12 January 2024)
9 MEDSAFE, (2013). Steroid Rebound – A Topical Issue. MEDSAFE. Available at: https://www.medsafe.govt.nz/profs/PUArticles/June2013Steroid.htm (Accessed: 12 January 2023)
10 Harlan, S.L. (2008). Steroid acne and rebound phenomenon. Journal of Drugs in Dermatology. 7(6). 547-550. Available at: PMID:18561585
11 Aggerwal, A., Maddin, S. (1982). Alclometasone Dipropionate in Psoriasis: A Clinical Study. Journal of International Medical Research. 10, 414-418. Available at: https://doi.org/10.1177/030006058201000605
12 Trookman, N.S., Rizer, R.L. (2011). Randomized Controlled Trial of Desonide Hydrogel 0.05% versus Desonide Ointment 0.05% in the Treatment of Mild-to-moderate Atopic Dermatitis. The Journal of Clinical and Aesthetic Dermatology. 4(11), 34-38. Available at: PMID:22125657
13 Torok, H.M., Jones, T., Rich, P., Smith, S., Tschen, E. (2005). Hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%: a safe and efficacious 12-month treatment for melasma. Cutis. 75(1), 57-62. Available at: PMID:15732437
14, 20 Lenane, P., Macarthur, C., Parkin, C.P., Krafchik, B., DeGroot, J., Khambalia, A., Pope, E. (2014). Clobetasol Propionate, 0.05%, vs. Hydrocortisone, 1% for Alopecia Areata in Children. A Randomized Clinical Trial. JAMA Dermatology. 150(1). 47-50. Available at: https://doi.org/10.1001/jamadermatol.2013.5764
15 Jorizzo, J., Levy, M., Lucky, A., Shavin, J., Goldberg, G., Dunlap, F., Hinds, A., Strelka, L., Baker, M., Tuley, M., Czernielewski, J.M. (1995). Multicenter trial for long-term safety and efficacy comparison of 0.05% desonide and 1% hydrocortisone ointments in the treatment of atopic dermatitis in pediatric patients. American Academy of Dermatology. 33(1). 0-77. Available at: https://doi.org/10.1016/0190-9622(95)90014-4
16 Salava, A., Perala, M., Pelkonen, A.S., Remitz, A., Makela. (2022). Safety of tacrolimus 0.03% and 0.1% ointments in young children with atopic dermatitis: a 36-month follow-up study. Clinical and Experimental Dermatology. 47(5). 889-902. Available at: https://doi.org/10.1111/ced.
17 Sigurgeirsson, B., Boznanski, A., Todd, G., Vertruyen, A., Schuttelaar, M.L.A., Zhu, X., Schauer, U., Qaqundah, P., Poulin, Y., Kristjansson, S., von Berg, A., Nieto, A., Boguniewicz, M., Paller, A.S., Dakovic, R., Ring, J., Luger, T. (2015). Safety and Efficacy of Pimecrolimus in Atopic Dermatitis: A 5-year Randomized Trial. Pediatrics. 135(4). 597-607. Available at: https://doi.org/10.1542/peds.2014-1990
18 Torok, H.M., Jones, T., Rich, P., Smith, S., Tschen, E. (2005). Hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%: a safe and efficacious 12-month treatment for melasma. Cutis. 75(1), 57-62. Available at: PMID:15732437
19 Mount Sinai, (no date), Telangiectasia. Mount Sinai. Available at: https://www.mountsinai.org/health-library/symptoms/telangiectasia#:~:text=Telangiectasias%20of%20the%20skin%20occur,in%20the%20formation%20of%20telangiectasias. (Accessed: 12 January 2024)

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