When topical steroids stop working

When the steroid cream stops working

You've been given a stronger cream. It worked for a fortnight. The flare came back. You were told to keep going with emollients, that they'll grow out of it, that this is just how eczema is.

Then someone mentioned injections.

There is a step between those two things, and most people are never offered it. This page explains what it is, why it exists, and how to work out whether it applies to you.

The question nobody asks

When steroids stop working, the usual response is to go stronger, then to go systemic. What's rarely asked is why they stopped working - and the answer determines whether escalating is the right move at all.

Four explanations are far more common than treatment resistance:

The skin is colonised with bacteria. This is the big one, and the most frequently missed. Staphylococcus aureus is present on the lesional skin of the great majority of people with atopic dermatitis, against a small minority of people without it. It isn't a passive passenger. Staph produces toxins that act as superantigens, driving inflammation directly and continuously.

A steroid suppresses that inflammation. It does nothing to the organism generating it. So the skin settles while the cream is on and relapses within days of stopping - which looks exactly like treatment failure, and isn't. It's a treatment aimed at half the problem.

Not enough is being used. Most people apply considerably less topical steroid than they've been prescribed, usually because they've been warned about steroids so effectively that they use them nervously. Undertreated eczema is indistinguishable from resistant eczema.

Treatment stops too soon. Skin can look settled while inflammation continues underneath. Stopping at visible clearance is a reliable route back to a flare.

The diagnosis isn't quite right. Allergic contact dermatitis, scabies and psoriasis are all mistaken for eczema, and none behave as expected on steroid creams.

Genuine tachyphylaxis - skin becoming less responsive to the drug - is described in the literature but is a far less common explanation than any of the above.

Why this matters: if the reason is colonisation or undertreatment, a biologic will work - of course it will, it suppresses inflammation powerfully - but you'll have moved to systemic immune modulation to solve a problem a better-designed topical plan addresses. That's a significant decision to make without first ruling out the simpler explanation.

The step in between

Between "topical steroids have failed" and "let's discuss injections" there is an approach most patients are never offered: an individually compounded topical preparation that treats the inflammation and the bacterial colonisation together, adjusted repeatedly as the skin changes.

This is what we do, and it's all we do.

The preparation combines a topical corticosteroid, an antimicrobial and a moisturising base, made up to individual prescription rather than taken off a shelf. The proportions are set according to severity, body site and age, and - this is the part that matters - stepped down over the following weeks as the skin settles. The aim is to reach the lowest effective treatment, not to stay on the starting one.

It is not a stronger cream. It's a differently designed one, reviewed frequently.

What it involves

• A consultation, then reviews at two weeks and four weeks
• Adjustment at each review rather than a single prescription
• No blood tests, no injections, no hospital visits
• Entirely reversible

What happens when you book

1. Consultation. We look at your photographs together, go through everything you've already tried and what happened each time, and work out why it stopped working. Most patients say this is the first time anyone has explained it.

2. A plan - or an honest no. If we don't think we can help, we'll say so and tell you what we'd do instead.

3. Two-week review. We adjust based on what your skin has actually done, not what it was supposed to do.

4. Four-week review. We adjust again and set the plan for stepping the treatment down.

Consultations are online, wherever you are. Prices are published - no registration needed to see them. Appointments are usually available the same day.

What we'll tell you that others won't

These preparations are made to individual prescription, which means they haven't been through the randomised controlled trial programme that licensed drugs have. The published evidence is case series and clinical experience, not controlled trials.

Most clinics wouldn't put that on their website. We would rather you heard it from us, weighed it properly, and decided with your eyes open - because the people who come to us have usually been promised a lot by a lot of people, and are rightly tired of it.

Who we help most

You're likely to be in the right place if any of this sounds familiar:

• The cream works, you stop, and it's back within days
• The skin keeps getting infected, weepy or crusted
• You're on stronger and stronger steroids for shorter and shorter relief
• You've been told there's nothing else short of injections
• A biologic has been suggested and you'd like to try something reversible first
• You're worried about cumulative steroid exposure and want a plan to reduce it, not just reassurance
• Nobody has ever explained why the treatment stopped working

That last one is the most common thing our patients say. Not that treatment failed - that nobody could tell them why.

We're not right for you if the diagnosis isn't eczema, if you need in-person examination, patch testing or a biopsy. The reviews are the part of what makes the treatment effective, not an optional add-on.

What the alternatives actually ask of you

If you're weighing this against systemic treatment, it helps to see plainly what each option involves.

Older systemic immunosuppressants. Tablets taken under specialist supervision. Effective and inexpensive. They suppress the immune system broadly rather than selectively, carry toxicity that accumulates with exposure, and require regular blood monitoring. Usually used for a defined period to break a severe flare rather than for long-term control.

Injectable targeted therapies. Injections, given every few weeks and continued long-term. They block specific inflammatory signals rather than suppressing immunity as a whole, and need no routine blood monitoring, which is a genuine advantage. Response builds over weeks rather than days, and in the UK, funding approval can add to that. Eye irritation and conjunctivitis are recognised effects of the group most used in eczema. Guidelines generally make this the preferred first systemic option in adolescents and in pregnancy.

Oral targeted therapies. Tablets, and the fastest route to relief from itch, with some people improving within days. They also carry the most demanding safety profile of the three: regulators require counselling on serious infection, cardiovascular events, blood clots and malignancy, screening before starting, and blood tests throughout. Not used in pregnancy or breastfeeding. Guidelines generally place them after an injectable has been tried or ruled out.

Set against that: no injections, no blood tests, no hospital visits, entirely reversible, and you can stop whenever you want.

None of this makes systemic treatments bad - they are transformative for the right patient, and for some people they are exactly the right answer. The question is whether you've established why the topicals failed before committing to one. Most people haven't.

What happens when you book

1. Consultation. We look at your photographs together, go through everything you've already tried and what happened each time, and work out why it stopped working. Most patients say this is the first time anyone has explained it.

2. A plan - or an honest no. If we don't think we can help, we'll say so and tell you what we'd do instead.

3. Two-week review. We adjust based on what your skin has actually done, not what it was supposed to do.

4. Four-week review. We adjust again and set the plan for stepping the treatment down.

Consultations are online, wherever you are. Appointments are usually available the same day.

*From our 2022–2026 outcomes audit of more than 1,500 new patients who completed a POEM score at each review. Not every patient returns a score at every review. A meaningful improvement means a fall of 4 or more POEM points. Individual results vary.

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