Is topical clobetasol safe for the scalp?

On the Safety of Topical Clobetasol 

I've often asked if applying topical clobetsol steroid cream, lotion, foam or shampoo to the scalp is safe. Before we answer that, it's important to understand what clobetasol is and why it's used. 

Clobetasol is a class I steroid. Hydrocortisone is Class 7.

There are seven classes of steroid strengths. Class 1 steroids are the strongest and class 7 are the weakest. Clobetasol is a class 1 steroid and requires a prescription (in most countries). Hydrocortisone is a class 7 steroid that can often be bought 'over the counter' at the local drug store.  In simple terms, clobetasol is about 600 times stronger than hydrocortisone.  That does not simply equate to dangerous. It simply equates to stronger. A common steroid potency chart is found in the list below

TOPICAL STEROID POTENCY COMPARISON

Frequency, Duration, Amount

When someone tells me they are are using clobetasol, the first thing I want to know is how much are they using and how often are they using it? It comes as a surprise to some that how much steroid a patient is using is usually more important to me that the how often.  A patient who used clobetasol every day but it takes them 5 months to use up their bottle has a very different safety risk profile than someone who is using clobeetasol every day but goes through a bottle every two weeks.  Similarly, a patient who uses clobetsol twice per week could be using more than a patient using it everyday. The amount matters!

On the Fear of Topical steroids

There is quite a bit of inappropriate and misguided fear about topical steroids. I'm not saying topical steroids don't deserve respect, because they do. However, the fear that permeates society mainly comes form poor knowledge and also from the misuse of these products among the general population. Sadly, sometimes this misdirected fear comes from unethical practice and misguided motives. It's tough to change that but I can give at least 1000 examples from my own practice over the years of these situations:

A clinic wanting to sell product A for a child advising a parent "Oh you wouldn't want to put a steroid on your child would you?"

A clinic wanting to sell treatment B to there patient saying "Steroids are not safe. This treatment I am recommending is drug-free and natural."

A clinic wanting to establish 'trust' with a client and advises them "You need to stay away from that other clinic recommending you that steroid treatment. What was recommended is very unsafe. I can't believe they wanted to give you that. They should be reported."

It's difficult in the short term to change how hair medicine gets practiced throughout the world and it's difficult to regulate clinics and practitioners that prey on the vulnerability of their clients and patients. However, we can first and foremost recognize these patterns and spread accurate information as a starting point. I can assure you it's not always a popular view. Topical steroids can be quite safe when used appropriately.  Of course, they are unsafe when used inappropriately.

Logic, Practicality and other Forgotten Issues

When it comes to topical steroids, we need to be logical and practical.  Practical thinking does us good as humans, and we should not forget these principles:

A. It's safe to walk to your across the parking lot to your car on a blazing hot summer day, but it would not be appropriate to walk for hours across the entire city on the same hot day.

B. It's safe to add a bit of hot chili pepper to dish that one is preparing for dinner, but adding the entire chili pepper bottle would just not make sense.

C. It's safe to add a dab of toothpaste to one's toothbrush, but squeezing out the whole tube onto the brush would just be bizarre. 

D. It's generally safe to use a bit of topical steroid for short periods of time to calm down an inflammatory scalp disorder that is causing a patient extreme discomfort, itching and burning. 

E. It's generally safe to use a bit of topical steroid for short periods of time to reduce scalp inflammation that is preventing hair growth.

Safety Monitoring

Anyone using topical steroids needs to be monitored by an expert who knows how to use these prescriptions and what side effects they carry.  

First, patients using the steroid must understand how much to use and for how long. They should carefully record the amount of steroid they are using on a monthly basis and carefully record how long it takes them to go through their tube or bottle. 

Excessive use of topical steroids does lead to thinning of the skin, and even side effects from absorption into the body. These side effects are relatively uncommon with proper doses. 

Use of Topical Clobetasol in Hair Loss

In hair dermatology, we use topical steroids for many reasons. Topical clobetsol is commonly used to treat alopecia areata, and scarring alopecias such as lichen planopilaris (LPP). When used, these should be used for a short of time as needed and always under supervision. Frequent breaks from the steroid use ("steroid holidays")  are frequently helpful. For children with inflammatory scalp conditions that require topical steroids, we often prescribe topical steroids for 4-6 weeks straight and then give a 2-4 week steroid-free holiday period. This cycle is often repeated.

Summary 

Topical steroids can be both safe and effective when used appropriately. Of course, the don't help everyone and may not be enough of an immunosuppressive type treatment for certain kinds of hair loss. For example, some patients with alopecia areata and some patients with lichen planopilaris find that topical steroids help but not enough and hair loss still occurs despite using them.  In such as case the physician needs to decide whether to continue the topical steroid and add other immunosuppressive treatments or whether to stop the topical steroids altogether in place of the new immunosuppressive treatments.