Topical glucocorticoids are important topical dermatological drugs with high efficiency and safety, and are the first-line treatment for many dermatological diseases, but there are problems of “abuse” and “fear” in clinical practice. In order to standardize topical glucocorticoids, maximize their therapeutic effects and reduce adverse reactions, the Environmental and Occupational Dermatology Group of the Dermatology and Venereology Committee of the Chinese Society of Integrative Medicine has organized some domestic experts to develop this consensus. I. Concept and classification 1. Concept: Glucocorticoids are synthetic adrenal glucocorticoids, which belong to steroid hormone class, also known as corticosteroids. Since corticosteroids include sex hormones and derivatives of vitamin D3, the name glucocorticoid (referred to as hormone) is used in this paper. 2. Strength of action classification: The strength of action of topical glucocorticosteroids can be classified into many levels according to the skin vasoconstriction test and other methods. The classification method commonly used in clinical practice is the 4-level classification method, which divides them into 4 categories: superpotent, potent, moderately potent and weakly potent. The structure of the hormone is the main factor in determining its strength of action, but the concentration and dosage form also have a greater impact on it. Certain ingredients added to compound formulations, for example, the osmogenic agent nitrogen ketone or the keratolytic agent salicylic acid, can also increase the strength of hormones. In addition, the grading of the strength of action of hormones does not always parallel the clinical efficacy; for example, dinaide is graded as a weak hormone, but the clinical efficacy and action are comparable to some medium-acting hormones. Superpotent hormones and potent hormones are indicated for severe, hypertrophic lesions. They should not be used on the face, breasts, pubic area and folds unless specifically needed. Commonly used super-potent hormones at home and abroad include 0.05% clobetasol propionate gel, ointment, cream and foam; 0.05% diflucan acetate ointment and 0.1% fluphenazole cream, etc. Strong hormones include, 0.1% Haxenaid cream, ointment and solution, 0.1% Encinaid ointment, 0.05% betamethasone dipropionate gel and ointment, 0.05% clobetasol propionate solution (scalp agent), 0.025% beclomethasone propionate ointment, 0.25% desoximetasone ointment and cream, 0.05% halometasone cream, 0.05% betamethasone dipropionate cream or Ointment, 0.1% betamethasone valerate ointment, 0.05% fluphenazine acetate ointment, cream or gel and solution, 0.1% mometasone furoate ointment, 0.005% fluticasone propionate ointment, 0.1% tretinoin ointment, 0.5% tretinoin cream, etc. Some drugs still use “cream” as the property of the dosage form. Medium-acting hormones are suitable for mild to moderate lesions and can be applied continuously for 4 ~ 6 weeks; children <12 years old should not be used continuously for more than 2 weeks; they should not be used on a large area for a long time. Commonly used medium-acting hormones are, 0.1% mometasone furoate cream and lotion, 0.1% hydrocortisone butyrate ointment, cream and lotion, 0.05% fluticasone propionate cream, 0.1% tretinoin cream and ointment, lotion, 0.12% betamethasone valerate foam, 0.025% fluphenazole ointment and cream, 0.2% hydrocortisone valerate cream, 0.05% betamethasone dipropionate Lotion, 0.1% betamethasone valerate cream and lotion, 0.05% clobetasone butyrate ointment, etc. Weak-acting hormones are suitable for mild and moderate lesions (including children's dermatoses, face and tender skin areas), and can be used for a short period of time over a large area, or for a long period of time if necessary. Commonly used weak hormones include 0.05% dextran ointment, cream, gel, foam and lotion, 0.1% betamethasone valerate lotion, 0.01% fluphenazole cream and 0.05% fluphenazole solution, 0.025% tretinoin cream and water, and various topical formulations of hydrocortisone, prednisone and dexamethasone such as 0.5% hydrocortisone acetate ointment, 0.05% dexamethasone acetate ointment, 0.05% dexamethasone acetate ointment, 0.05% dexamethasone ointment and 0.05% dexamethasone ointment. Dexamethasone ointment, 0.025% fludrocortisone acetate ointment, etc. 3. Therapeutic index and soft hormones: Therapeutic index is an index used to evaluate the efficacy of topical glucocorticoids and systemic adverse effects. Therapeutic index = the number of patients with 75% to 100% improvement in symptoms after 21 d of treatment / the number of patients with suppressed hypothalamic-pituitary-adrenal axis (HPA axis). The higher the therapeutic index, the less adverse effects caused by systemic absorption. Soft hormone means that the hormone has little systemic absorption or can be rapidly broken down and metabolized into inactive degradation products after being absorbed in the skin, while retaining a high degree of activity locally, so the HPA axis suppression and other systemic adverse reactions are greatly reduced and the therapeutic index is greatly improved. Soft hormones are suitable for the elderly, infants and children and for larger areas. The existing soft hormones in China are mometasone furoate and fluticasone propionate. It should be noted that soft hormones are not the standard for measuring the topical safety of the skin. The key to improving the safety of topical hormones is still to choose the hormone preparation with the lowest possible efficacy under the premise of controllable symptoms. II. Pharmacological effects and adverse reactions Glucocorticoids have clear anti-inflammatory, anti-allergic, immunosuppressive and anti-proliferative effects, and may also induce or aggravate local infections, such as aggravating acne and scabies, leading to skin atrophy, capillary dilation, hirsutism, pigment changes, hormone dependence and rebound, perioral dermatitis, indiscernible ringworm, indiscernible folliculitis, contact dermatitis, inducing ulcers, inducing folliculitis or corn rash, fat or muscle atrophy, and other adverse reactions. Periocular use may cause increased intraocular pressure, glaucoma, cataract, aggravated corneal and conjunctival viral or bacterial infections, and in severe cases, blindness. Systemic adverse reactions such as HPA axis inhibition, Cushing's syndrome, growth retardation in infants and children, elevated blood glucose, teratogenicity and dwarfism may be caused by long-term systemic application. Indications, contraindications and issues to be noted before topical application 1. Indications: Dermatitis and eczema skin diseases, erythema and scaling skin diseases, autoimmune skin diseases, cutaneous vasculitis, non-infectious granuloma, cutaneous lymphocytic infiltration, vitiligo, baldness, hemangioma, proliferative scar, cutaneous T-cell lymphoma, etc.; 2. Contraindications: Hypersensitivity to glucocorticoids or their matrix and other components is absolutely contraindicated. Various skin infections, such as fungal, bacterial and viral infections, rosacea, acne, perioral dermatitis, skin ulcers, etc. are relatively contraindicated, and the risk-benefit ratio must be assessed, and their use should be considered only on the basis of adequate control of the original disease. Whether the strength and dosage form of the selected glucocorticosteroid are appropriate; whether the patient understands the effects, adverse reactions, methods of use and precautions of the proposed drug; whether the condition can be controlled within an appropriate time; whether the dosage can be reduced until it is stopped soon after the condition is controlled. The patient or family members should be informed of the necessity of the medication, precautions, possible adverse reactions and methods of prevention. Finally, it must be noted that the examination and treatment of the causes and triggering factors should not be neglected when using hormones. Initial strength selection: The type of skin disease and the nature of the lesion are the primary factors to be considered when selecting topical hormones. The principle is to first choose the smallest strength hormone among the sufficient strength hormones and avoid using overly strong or under-strength preparations. Generally keratinized, mossy or hypertrophic lesions as well as lesions of discoid lupus erythematosus, vitiligo, pemphigus and herpetiform aspergillosis should be preferred to strong hormones; mild erythema, tiny papules or desquamative lesions, especially those on tender parts of the body, should be preferred to weak hormones; other dermatitis, flexural psoriasis and erythrodermatitis can be selected to medium-acting hormones. 2.Dosage form selection: select according to the nature and location of skin lesions. Ointment with poor permeability and strong emolliency is suitable for hypertrophic, keratotic and exfoliative lesions, especially those in the palmoplantar area, but not for non-hypertrophic and keratotic lesions in tender areas such as the face. Creams and gels can be used for all kinds of skin lesions including acute, subacute and chronic. Gels, lotions and solutions are more suitable for scalp and hairy areas. Tinctures and spirits are suitable for hypertrophic, mossy lesions. Excessively hypertrophic lesions hormone can be sealed to increase the efficacy. 3.Compound preparations and combination therapy: lesions suspected of combined bacterial or fungal infection can use compound preparations containing corresponding anti-microbial drugs for 1~2 weeks; plaque psoriasis can use compound preparations containing carbotriol or tazarotene; hypertrophic and keratinized lesions can use compound preparations containing keratin relaxants. 4. Method of use and course of treatment: choose the hormone of suitable strength for continuous application at the beginning of treatment until the symptoms are controlled. Dermatitis and eczema skin diseases are mostly controlled within 1~2 weeks. If the effect is unsatisfactory after 2 weeks of use, in addition to considering whether the strength of the drugs used is sufficient, it should also consider whether the diagnosis is correct, whether the causes and triggers are removed, whether there is co-infection, whether there is allergy to the hormones used and patient compliance, etc., and deal with them accordingly. After the disease is controlled, i.e., the itching and rash have subsided significantly, the hormone should be replaced with a hormone of lower strength than the initial hormone for a period of time or with a non-hormonal preparation. For certain skin diseases whose causes have been removed, such as contact dermatitis, the drug can be discontinued, while for other chronic recurrent diseases, such as chronic eczema and atopic dermatitis, after the lesions have subsided significantly, the following maintenance treatments can be chosen: (1) long course of intermittent therapy: after the lesions have subsided, the drug can be used intermittently for 1~2 d per week for about six months, which can effectively reduce recurrence; (2) sequential therapy: hormonal and non-hormonal preparations are used once a day until the lesions have subsided. (2) Sequential therapy: hormonal and non-hormonal preparations are used once a day until the lesions have completely subsided, and then non-hormonal preparations are used intermittently for maintenance. Erythema scales skin disease, for example, psoriasis non-acute stage usually adopts sequential therapy, initially using strong hormone or hormone combined with vitamin D3 derivatives or vitamin A acid or directly using the compound application for 2 ~ 4 weeks, until the lesions become flat and the symptoms are controlled, then use non-hormone preparations to maintain treatment for 2 ~ 3 months. Vitiligo and pemphigus require more than 3 months of strong or medium-strength hormone application to see the effect. Skin vasculitis, non-infectious granuloma, skin lymphocytic infiltration, proliferative scar, skin T-cell lymphoma, etc. often need long time intermittent medication on demand. 5.Dosing frequency: Generally 1 ~ 2 times a day, the number of times of use should not be too much. 6.Dosage: Fingertip unit (FTU) refers to the amount of ointment squeezed out from a 5 mm inner diameter tube of ointment to reach the distance between the distal interphalangeal joint and the end of the index finger, which is about 0.5 g. It can be applied evenly to both palms once, according to which the dosage of the corresponding lesions can be calculated. V. Special populations and special parts of the drug 1. Pregnant or lactating women: the effect of topical hormones on human fetal development is not completely clear, so use with caution during pregnancy. When it must be applied, weak, medium-acting or soft hormones can be used after obtaining the patient's consent. Do not use fluorinated hormones in early pregnancy. Do not apply to the breast during lactation. 2. Infants, children and the elderly: Because of thin skin, poor metabolism and excretion function, long-term application in a large area is likely to produce systemic adverse reactions due to systemic absorption, so generally choose weak or soft hormones such as mometasone furoate. Unless there is a special clinical need or the drug specifically states, use strong and super strong hormones with caution. Do not use ointments in the diaper area of infants (equivalent to sealing the packet would increase absorption). Most hormones do not have clear age restrictions. The instructions for the strong hormone halometasone state that it can be applied to children under 2 years of age, but should not be used continuously for more than 7d. 3. Tender skin areas: such as the face, periocular area, neck, axilla, groin, medial femur and pubic area have thin skin and high hormone absorption rate, and are more likely to produce epidermal atrophy, atrophy lines, local absorption and dependence/rebound syndrome, and should be prohibited for strong, Fluorine-containing preparations should be prohibited. When it is necessary to use, you can choose Denide preparations, mometasone furoate gel or cream, fluticasone propionate cream, hydrocortisone preparations, etc. Generally eczema dermatitis medication 1 ~ 2 weeks, erythema scales skin disease 2 ~ 3 weeks, other baldness, vitiligo, lupus erythematosus, etc. can be extended appropriately. 4, hairy parts: such as the scalp, according to the nature of the lesions to choose the appropriate strength hormone, the dosage form can choose solution, lotion, gel. VI. Monitoring of adverse reactions Adverse reactions should be actively monitored. It is recommended that strong and super strong hormones should be checked every 2 weeks, medium-acting hormones should be checked once every 3-4 weeks, and weak hormones should be checked once every 4-6 weeks to observe whether there are any systemic and local adverse reactions. The standardized use of glucocorticoids is relatively safe. Overseas reports show that long-term maintenance treatment of atopic dermatitis with 2~3 times a week (no more than 15 g per month for infants, 30 g per month for children, and 60~90 g per month for youth and adults) did not show any significant local and systemic adverse effects even with the use of potent hormones. No HPA axis suppression was observed in patients with psoriasis treated with calcipotriol/betamethasone dipropionate ointment for 4 weeks, followed by 4 to 8 weeks of on-demand use in 15% to 30% of the body surface area. Children treated with 0.1% hydrocortisone butyrate cream 3 times daily or 0.05% dextran gel twice daily or fluticasone propionate lotion twice daily for 4 weeks also did not show HPA axis suppression. VII. Conclusion This consensus is based on the reference of domestic and international literature and many discussions with the experience of various experts. The available evidence shows that topical hormones are still the first choice for the treatment of many skin diseases, and their standardized application can significantly improve efficacy, reduce adverse effects and effectively reduce disease recurrence. Unnecessary "fear" can significantly reduce efficacy. Physicians at all levels should continue to summarize their experience in the process of hormone application, strengthen the monitoring of adverse reactions, and gradually improve the standard of hormone use in China.