Steroid-free and antibiotic-free: why balms make this promise

The first-aid aisle has two kinds of small tubes that have been there for decades: hydrocortisone creams for itch and rashes, and antibiotic ointments for cuts. The skin-care aisle now has balms proudly labelled “steroid-free” and “antibiotic-free”. Both are responding to something real. Here’s what those over-the-counter medicines do well, where the problems come from, and what a balm without them can honestly offer.

What over-the-counter hydrocortisone does

Hydrocortisone is a corticosteroid, a medicine that calms inflammation (the redness, swelling and itch your immune system produces). It’s the mildest member of the topical steroid family. In Canada, hydrocortisone at 0.25 to 1 per cent is sold without a prescription; stronger steroids need one.

Health Canada’s labelling standard describes what it’s for: temporary relief of itching from minor skin irritation, inflammation and rashes, including eczema (the itchy, inflamed skin condition), insect bites, poison ivy and contact reactions. It’s applied to the affected area up to four times a day, for external use only.

The label also sets limits, and they matter. Stop and ask a health care practitioner if symptoms persist for more than seven days, worsen, or clear up and come back within a few days. Don’t use it around the eyes, on large areas of the body, for diaper rash, or on children under two.

For eczema, topical corticosteroids remain the first-line treatment for flares. The Eczema Society of Canada notes they’ve been used for more than 50 years and remain the first medication class prescribed when eczema flares, and that untreated eczema carries its own risks, including infection and scarring.

Why long or careless steroid use is a problem

So why does “steroid-free” sell? Because the concerns behind it have a basis, even if they’re often exaggerated.

The Eczema Society of Canada puts it this way: side effects are mostly seen with prolonged use of more potent steroids over time. The best-known is skin thinning (atrophy), where the skin becomes fragile. The face and skin folds are most vulnerable because the skin there is thinner and absorbs more.

The evidence for the mild, intermittent use most people practise is reassuring. A 2023 systematic review of long-term studies, including two randomized trials lasting three and five years in children, found that intermittent use of mild-to-moderate topical steroids to treat flares probably makes little or no difference to skin thinning or growth. In the five-year trial, one case of skin atrophy was reported among more than 1,200 children using steroids. The authors were candid that gaps remain, and no long-term studies of “topical steroid withdrawal”, the burning, rebound rash described by some long-term users online, were found.

There’s a subtler issue with using an over-the-counter steroid on your own: it can mask things. Hydrocortisone will calm the redness of a fungal infection, a bacterial infection or an allergic reaction to something you’re still using, without fixing the cause, which is exactly why the label says to stop at seven days and get advice.

The Society’s position is the balanced one: used as directed, intermittently and for short periods, topical corticosteroids are safe and effective, and fear of them (“steroid phobia”) leads many people to undertreat eczema that would have responded.

What over-the-counter antibiotic ointments do

The other tube contains antibiotics such as bacitracin, polymyxin B or neomycin, alone or combined, in a petrolatum base. The idea is to prevent infection in cuts and scrapes. Three problems have accumulated around them.

They usually aren’t needed for clean minor wounds. A 1996 randomized trial published in JAMA compared plain white petrolatum with bacitracin ointment on 1,249 wounds from skin surgery in 922 patients. Infection rates were low and statistically similar (2.0 per cent with petrolatum, 0.9 per cent with bacitracin), and healing was the same at one, seven and 28 days. The authors concluded that plain petrolatum is a safe, effective wound ointment with minimal risk of causing allergy.

They cause allergy. In that same trial, the only cases of allergic contact dermatitis (a rash from an immune reaction to a substance on the skin) occurred in the bacitracin group. Neomycin is a well-known offender: a 2025 study of more than 30,000 patch-tested patients in northern Italy found 2.3 per cent were sensitized to it, with rates highest in older people using topical medicines on leg dermatitis. Three-quarters of those allergic to neomycin also reacted to other ingredients common in creams, such as lanolin or preservatives. A 2017 review in Clinical Microbiology Reviews likewise flags local hypersensitivity reactions as a particular problem with older topical agents like bacitracin. The frustrating part is that an allergic reaction to the ointment looks like the wound getting worse, so people apply more.

They drive resistance. The same 2017 review notes limited evidence for widespread preventive use of topical antibiotics and rising rates of bacterial resistance to them, including to mupirocin, a prescription ointment. Every unnecessary application adds selection pressure. Topical antibiotics have real jobs treating actual bacterial skin infections, and keeping them working is part of why experts steer away from routine use on every scrape.

What a steroid-free, antibiotic-free balm can do

This is where balms come in. A balm built on petrolatum, plant oils, waxes and butters, without hydrocortisone or antibiotics, does three things well:

• Protects. It forms a film over cracked or scraped skin that keeps water in and irritants, dirt and friction out, which is exactly what the JAMA trial showed plain petrolatum doing for healing wounds.
• Moisturizes. For eczema, regular moisturizing is the foundation that everything else sits on. Well-moisturized skin flares less often and itches less, and a balm applied to damp skin holds moisture better than most lotions.
• Avoids two common allergens and one resistance risk. For someone who reacts to neomycin or bacitracin, or who simply doesn’t want to use antibiotics without a reason, a plain balm is the better default for minor wounds.

The label “steroid-free” is also honest in a way worth noticing: it tells you the product isn’t a medicine, which mostly reassures people who’ve had bad experiences or who want to know exactly what’s going on a child’s skin. For a comparison of what’s on the market, see the Panel’s reviewed balms and ointments.

What it can’t do

The limits are just as important, because the marketing can blur them.

• A balm doesn’t treat inflammation. If a patch of eczema is red, thick and intensely itchy, moisturizer alone will often not settle it. That’s what a corticosteroid is for, and delaying it can mean a longer, worse flare.
• A balm doesn’t treat infection. If a wound is spreading redness, hot, swollen, oozing pus or accompanied by fever, it needs a doctor, not a thicker layer of anything from the drugstore.
• “Free-from” isn’t “reaction-free”. Plant oils, fragrance, lanolin and essential oils in a “natural” balm can cause contact allergy too. If a balm stings or makes things redder, stop using it.
• A balm on top of the wrong thing seals it in. Occlusive balms hold whatever’s underneath against the skin, so use them on clean skin.

A reasonable routine for many families: plain balm or petrolatum for clean cuts, scrapes and dry patches; short, as-directed use of over-the-counter hydrocortisone for a mild itchy rash, stopping at seven days if it isn’t better; and a doctor or pharmacist for anything infected, spreading, on a young child’s face, or not improving after two weeks.

The bottom line: hydrocortisone and antibiotic ointments earned their place on the shelf, and the problems come from using them longer or more often than intended. A steroid-free, antibiotic-free balm is a good tool for protecting and moisturizing skin, and a poor substitute for treating inflammation or infection. Knowing which job you’re doing is most of the battle.