Misuse of topical corticosteroids on facial skin. A study of 200 patients.

Intravitreal Triamcinolone

QUESTION: A 50-year-old woman is seen for evaluation of a facial eruption that has been present intermittently for at least 5 years. The process is located on her mid and lower face. She has used the topical corticosteroid creams diflorasone diacetate 0.05% and hydrocortisone valerate 0.2% for a prolonged period. Indeed, she presents crimped empty tubes to us in hopes of refills (figure 1). These preparations provide temporary relief, but the eruption always returns. Figure 1 Nearly empty tubes of medium- and high-potency topical steroids presented by patient Examination shows that she has a light complexion and marked erythema and scaling of the lower face, extending up to the cheeks. The lower lids show minor involvement (figure 2). The eruption spares the vermilion border of the lips and the lips themselves. Figure 2 Marked erythema and scaling of the patient's lower face What are the diagnosis, differential diagnosis, and treatment of this condition? What role do prescription topical steroids play in this eruption? ANSWER: This patient has steroid-induced perioral dermatitis, a condition marked by perioral or periorbital erythema and scaling with or without papules that characteristically shows a rim of sparing around the vermilion border of the lips. The process usually starts in a perioral distribution with later involvement of the chin, nasolabial folds, and occasionally the eyelids. It occurs mostly in women. The differential diagnosis includes classic perioral dermatitis, rosacea, and acne. Perioral dermatitis can begin by itself and is seen mostly in women aged 15 to 50 years,1 although it also may rarely affect prepubertal children of both sexes.2 Perioral dermatitis can become steroid-induced perioral dermatitis after prolonged use of topical corticosteroids on the face. Steroid-induced perioral dermatitis is differentiated from common perioral dermatitis by history and clinical behavior. Patients with rosacea and acne can also develop steroid rosacea, steroid acne, or the red-face syndrome after corticosteroid abuse.3 Steroid-induced facial dermatoses tend to have more erythema, inflammation, and scaling than their noniatrogenic counterparts. Mid- or high-potency topical corticosteroids are known to exacerbate perioral dermatitis, acne, and rosacea. They often initiate a cycle of temporary relief and increasingly severe flare-ups on attempt to stop the medicine. This has been described as an “addiction” of the skin to the steroid, requiring increasingly larger and more frequent applications of steroid creams to bring relief.4 Although temporarily reducing the inflammatory reaction, the steroid may increase the overgrowth of the bacteria through local immunosuppression. We have observed that patients with steroid-induced perioral dermatitis often present with vigorously squeezed tubes of corticosteroids that they have used for many months to years. These patients have tried to extract as much of the precious cream as possible to counter the latest flare of the dermatitis. Thus, we term this presentation the “tortured tube” sign. Treatment involves cessation of the topical steroid. Often this regimen initially results in moderate to severe flare-ups of the eruption. The administration of tetracycline, 500 mg by mouth twice a day, and cold tap water compresses will help to alleviate the inflammation. The lesions typically resolve after a few weeks, but occasionally may last as long as 6 months. To ensure therapeutic success, the physician must educate the patient about the course of the disease and the need to discontinue the use of topical corticosteroids. Prevention is more important than cure. Physicians should never prescribe mid- to high-potency topical corticosteroids for facial use without clear oral and written instructions that limit the time of application to no more than 1 to 2 weeks. Even weaker corticosteroid creams have been implicated in initiating facial disorders. Refills of these medicaments should not be given over the phone. A 15-gram tube of a steroid cream may last a patient 6 to 12 months when used only on the face and is sufficient to cause cutaneous addiction with the development of uncomfortable and unsightly dermatoses. In this case, on follow-up several months later, the patient's rash had resolved (figure 3). Figure 3 Resolution of the patient's rash several months after abstaining from steroid use

Cushing's syndrome (CS) is an endocrine disease by to glucocorticoids excess, depen dent or independent of adrenocorticotropic hormone (ACTH). The main cause is iatrogenic due to excessive use of glucocorticoids. To show the association between prolonged use of topical corticosteroids and the development of CS. An infant treated with topical corticosteroids due to seborrheic dermatitis. Due to long-term unsupervised use, he develops Cushing's syndrome characterized by obesity and compromised growth rate. Topical use of corticosteroids was discontinued and physiological replacement therapy was initiated with descending doses, achieving clinical improvement. Topical corticosteroids are widely used in clinical practice for management of dermatological pathologies. These are available in various presentations with va riable efficiency. The main determining factors in its action are the characteristics of the skin, the active principle of the drug, the potency and application technique, so that the adverse effects are observed more frequently in the use due to diaper dermatitis. The main adverse effect of long-term use is Cushing's syndrome which can be prevented through supervised use and progressive decrease. The rational and careful use of topical corticosteroids is essential to take advantage of the beneficial effects and avoid adverse effects.

Vitiligo treated with topical corticosteroids: Children with head and neck involvement respond well∗

Many a time topical corticosteroids are prescribed for genital dermatosis of diverse etiology without establishing a definite cause because of its potent anti-allergic and anti-inflammatory effect. Due to its micro-environment, drug penetration in genitocrural region is highest in the body and hence, it is more susceptible to the adverse effects of topical corticosteroid. The absorption quotient of the scrotum is found to be 40 times that of the forearm. In females, poor sensory discrimination, overlapping symptomatology and high anatomic variability of the vulval skin may obscure the unwarranted side effects of steroids. The post-menopausal vulva is particularly susceptible to the side effects of topical agents. Topical corticosteroids are useful in conditions like balanoposthitis, plasma cell balanitis/zoon’s balanitis, lichen sclerosus et atrophicus, balanitis xerotica obliterans, plasma cell vulvitis and contact dermatitis. Genital pruritus can be due to diverse causes and it is essential to find out the exact cause so that unnecessary use of topical corticosteroid is minimized. Alternatives to steroid should be considered like use of calcineurin inhibitors, tacrolimus and pimecrolimus 1%. In many inflammatory dermatoses, circumcision should be advised as first line measure so that prolonged use of corticosteroid can be avoided.

Periorificial dermatitis (POD) has historically been associated with topical corticosteroid use. Despite greater awareness and education on safer corticosteroid use, patients continue to present with POD, prompting a reassessment of risk factors for POD and analysis of whether corticosteroid use remains a dominant factor in POD. This retrospective cohort study characterizes the epidemiology of and risk factors for periorificial dermatitis in an academic medical center from 2008-2023. A total of 451 subjects with periorificial dermatitis were identified, of whom 79% were women and 80% were White. Age ranged from 4 months to 72 years with a mean of 32 years. Of records with clear steroid use data, 37% reported corticosteroid use within 6 months preceding diagnosis, and 23% reported topical corticosteroid use. Rates of preceding topical corticosteroid use, when excluding unknown cases, increased from 15% in subjects diagnosed 2012-2015, to 19% in 2016-2019, and 29% in 2020-2023 (p=0.03). 25% of subjects reported predisposing factors other than corticosteroids, such as facial sunscreens, whitening toothpastes, and heavy moisturizers. Topical antibiotics were the most prescribed treatment (82%). As anticipated, the use of corticosteroids commonly precedes the development of POD, however, the 37% rate of use in our study was significantly lower than historical reports, which range from 72 – 96%. A significant proportion of POD was not preceded by corticosteroid use, indicating further research might uncover other predisposing factors and better enable prevention of POD. The remaining association between corticosteroid use and POD indicates an ongoing need for education on corticosteroid risks.

Background: Melasma is a common acquired hyperpigmentation disorder primarily affecting the face. Topical corticosteroids are frequently used, often unsupervised, in melasma management but may induce alteration in pigmentation patterns and adverse sequelae. This study aimed to evaluate the impact of long-term topical corticosteroid use on facial melasma pattern alterations and associated pigmentary sequelae in affected patients. Methods: A retrospective cohort study was conducted involving 60 patients diagnosed with facial melasma who had a history of prolonged topical corticosteroid use. Baseline demographic and clinical data, corticosteroid usage patterns, changes in melasma distribution, pigmentary sequelae, and clinical outcomes following corticosteroid discontinuation were collected and analyzed descriptively. Results: The majority were female (n=52, 86.7%) with a mean age of 39.7±9.2 years. Following prolonged steroid exposure, a pigmentary pattern shift was observed in all participants: 40 (66.7%) developed a centrofacial pattern and 16 (26.7%) exhibited a mixed pattern. Post-inflammatory hyperpigmentation (PIH) was noted in 100% of cases. Despite subsequent dermatological treatment and cessation of TCS use, 48 patients (80.0%) reported no clinical improvement, and 52 (86.7%) showed no visible recovery at their final follow-up assessment. Conclusion: Prolonged topical corticosteroid use in melasma patients is strongly associated with significant alteration in melasma distribution and persistent pigmentary sequelae, highlighting the need for regulated corticosteroid use and increased patient education. Early dermatologic supervision is critical to prevent adverse pigmentary outcomes.

To assess the clinical and cost-effectiveness of once-daily use of topical corticosteroids versus more frequent use of same-potency topical corticosteroids in the treatment of people with atopic eczema. Electronic databases. Bibliographies of included studies and related papers. Experts in the field. Manufacturer submissions to the National Institute for Clinical Excellence. Studies were assessed for inclusion according to predefined criteria by two reviewers. Data extraction and quality assessment were undertaken by one reviewer and checked by a second reviewer. Clinical effectiveness data were synthesised through a narrative review with full tabulation of results. One RCT comparing moderately potent corticosteroids, eight RCTs comparing potent corticosteroids and one RCT comparing very potent corticosteroids were included. No RCTs or CCTs of mild corticosteroids were eligible. Most RCTs were of poor methodological quality, although two were judged to be of good quality. The only study that compared moderately potent corticosteroids found no significant difference between once- and twice-daily application. For potent corticosteroids, some statistically significant differences in numbers of patients responding to treatment were identified favouring twice-daily treatment, but these were inconsistent between physician and patient assessment and outcomes selected for analysis. Two studies found a significant improvement in some symptoms with once-daily mometasone furoate compared with twice-daily application of a different active compound, while a third study found no significant differences. One good-quality study favoured twice-daily application of fluticasone propionate ointment, while other studies found no significant difference or an improvement in one symptom but not others. The only study comparing very potent corticosteroids found a statistically significant difference in comparative clinical response in favour of three-times daily treatment, but no difference in number of patients with at least a good response. There appears to be little difference in the frequency or severity of short-term events, however data are limited. No published economic evaluations were identified. Given findings on clinical effectiveness, where outcomes from the comparators are similar, the relative cost-effectiveness of once-daily versus more frequent application of topical corticosteroids becomes a case of cost-minimisation, where the least-cost alternative should be favoured, all else being equal. Topical corticosteroid products included in this review have a wide variation in price; the cost per 30 g/30 ml varies between GBP0.60 and GBP4.88. Specific decisions on the least-cost alternative, between once-daily and more frequent application of products, will be determined by the relative price of the products being compared. Where patients can be appropriately prescribed once-daily treatment of a similarly priced product, a reduction in the quantity of topical corticosteroid used will be expected. However, issues related to pack size for prescribed products and subsequent waste (unused product) could easily erode any potential saving. The potential cost-savings on prescribed products are very small at a patient level; although given the large numbers of patients with atopic eczema, cost savings in theory could be substantial. The presence of specifically marketed 'once-daily' topical corticosteroids, which are relatively expensive (per unit price), may result in additional costs should there be a general recommendation in favour of once-daily use of topical corticosteroids, compared to more frequent use. The literature is very limited; that available indicates the clinical effectiveness of once-daily and more frequent application of potent topical corticosteroids is very similar, but it does not offer a basis for favouring either option. The cost-effectiveness of once-daily versus more frequent use will depend on the generalisability of the findings to the specific treatment decision and the relative product prices. The trials included in this review generally refer to moderate to severe atopic eczema, whereas most patients have mild disease, and furthermore most of the included trials report on potent topical corticosteroids (eight of 10 RCTs); therefore the generalisability of the findings is limited. Further research is required on the clinical and cost-effectiveness of once-daily versus more frequent use of same potency corticosteroids, specifically on mild potency products for mild to moderate atopic eczema. Outcomes should include quality of life and compliance.

Introduction: Topical corticosteroids are anti-inflammatory, immunosuppressive, and anti-proliferative drugs with profound efficacy. As it provides rapid relief, it is used for a wide spectrum of dermatological conditions. Rampant use of topical corticosteroids due to their easy availability gives rise to difficult-to-treat cutaneous adverse effects. Objectives: To determine the pattern of inappropriate use of topical corticosteroids and cutaneous adverse effects Materials and Methods: This was a hospital based cross-sectional prospective study conducted among 84 participants in the Department of Dermatology, Tribhuvan University Teaching Hospital, Kathmandu, from October 2020 to September 2021. Ethical clearance was obtained from the Institutional Review Committee. The participants fulfilling the inclusion criteria were included in the study. Results: Out of 84 cases, 59.5% were females and 40.5% were males. The mean age of participants was 30.4±9.1years. Dermatophytoses (71.4%) were the most common cause of inappropriate use of topical corticosteroids. The most common adverse effect was tinea incognito (23.8%). The most potent class (60%) of topical corticosteroids were misused. Most of the participants used topical steroids either for the duration of 1 week to 1 month ( 23.8%) or for more than 12 months (23.8%). Conclusion: Inappropriate topical corticosteroid use is a common problem due to its easy accessibility, resulting in several difficult-to-treat cutaneous adverse effects. So, awareness-raising activities regarding the proper use of corticosteroids have to be conducted.

Introduction Topical steroid damaged/dependent face (TSDF) is defined as the semi-permanent or permanent damage to the skin of the face precipitated by the irrational, indiscriminate, or prolonged use of topical corticosteroids (TCs), resulting in various cutaneous signs and symptoms and psychological dependence on the drug. The objective was to determine the clinical spectrum of TSDF. Methods This was an observational cross-sectional study conducted between May 2021 and April 2022, comprising 100 consecutive patients of TC-induced facial dermatoses who visited the skin and venereal disease OPD of a tertiary care hospital in northern India. Any case with a negative history of TC abuse was excluded from the study. Result The study included 100 subjects of TSDF. Females outnumbered males and the age of the patients ranged from 12 to 55 years with a mean age of 27.6 ± 10.07 years. The majority of patients used TCs on the face for pre-existing acne (41%), followed by melasma (20%). Over-the-counter (63%) was the most common method of acquiring TCs, followed by prescriptions from non-qualified persons (17%) and those provided by friends and relatives (9%). Mometasone (41%) was found to be the most commonly misused TC, followed by clobetasol (31%), and betamethasone (29%). The most common morphological presentation was erythema (42%), followed by acneiform eruptions (22%), steroid-induced rosacea (21%), hyperpigmentation (20%), hypertrichosis (5%) and perioral dermatitis (3%). Conclusion This study highlights the impact of misuse of TCs on the face in a single-center setting and provides a detailed description of the associated factors. Such studies could play a crucial role in addressing this issue. Moreover, strict enforcement of regulations on pharmaceutical companies and non-qualified individuals prescribing TCs could help in decreasing this growing health hazard.

The long-term use of topical corticosteroids can result in rosacea-like dermatitis or facial perioral dermatitis. The case of a 54-year-old man is described who developed topical corticosteroid-induced perioral dermatitis (TOP STRIPED), and the features of topical corticosteroid-induced rosacea-like dermatitis are reviewed. The man presented with a painful erythematous facial eruption. Additional history revealed that he had been applying a high-potency topical corticosteroid twice daily to the affected area. Correlation of the clinical history and cutaneous examination established a diagnosis of topical corticosteroid-induced rosacea-like dermatitis (TOP SIDE RED). Treatment of the patient’s TOP SIDE RED included not only discontinuing the high-potency corticosteroid but also initiating topical and oral antibiotics. In addition, a low-potency topical corticosteroid and metronidazole gel were also applied to the affected area. His facial rash resolved within three months and has not recurred. TOP STRIPED, also referred to as TOP SIDE RED, is an adverse side effect associated with the use of high-potency topical corticosteroids to the face. Management includes discontinuing the corticosteroid. Additional treatment may include a low-potency topical corticosteroid, antibiotics (systemic or topical or both), and/or topical calcineurin inhibitors, such as tacrolimus or pimecrolimus.

To compare the degree of ptosis and the risk of ptosis repair failure among patients with and without a history of topical corticosteroid use. Retrospective, case-controlled study examining topical corticosteroid use among adults with ptosis who underwent external levator advancement/resection (ELR) or Müller muscle conjunctival resection with at least 3 months postoperative follow-up. Comparative statistical analyses of surgical outcomes were performed amongst patients with and without history of topical corticosteroid use. A total of 240 patients (406 eyelids) met study criteria, of which 36 patients (44 eyelids) had history of topical corticosteroid use. Mean preoperative margin reflex distance was 0.20 mm and 0.58 mm for topical corticosteroid and non-corticosteroids users (p = 0.01). Mean preoperative levator function was 9.78 mm and 10.38 mm for topical corticosteroid and non-corticosteroid users (p = 0.02). The rate of ptosis repair failure was 30% and 16% in patients with and without a history of topical corticosteroid use (odds ratio 2.25, 95% confidence interval 1.10-4.55; p = 0.03). The rate of recurrence per surgical type in eyelids with and without history of topical corticosteroid use was: external levator advancement/resection 11/27 (41%) and 48/266 (18%) (odds ratio = 3.12, confidence interval 1.36-7.15 0; p = 0.01); Müller muscle conjunctival resection 2/17 (12%) and 9/96 (9%) (odds ratio 1.29, confidence interval 0.25-6.56; p = 0.76). Topical corticosteroid use is associated with more severe presenting ptosis and increased rates of ptosis repair failure. Compared to Müller muscle conjunctival resection, there is a significantly higher rate of ptosis repair failure in patients undergoing external levator advancement/resection.

Corticosteroids owing to their anti-inflammatory, immunosuppressive, anti-proliferative and vasoconstrictive effects are the most widely used agents in dermatology practice. Both topical and systemic corticosteroids are associated with side effects especially on long term use. Unsupervised and inappropriate use of topical corticosteroids (TCs) causes a plethora of adverse cutaneous effects like atrophy, telangiectases, erythema, rosacea-like picture, perioral dermatitis etc. Facial skin is more susceptible to these adverse effects due to thinness of the facial skin and enhanced percutaneous absorption of the topical preparations. Topical steroid damaged/dependent face (TSDF) is the term used for the harmful effects caused by prolonged and indiscriminate use of TCs on the face, subsequently leading to psychological dependence. It causes cosmetic disfigurement and has a negative impact on the quality of life of the patients. Withdrawal of TCs and psychological counselling are the cornerstone of management of TSDF.KeywordsFacial rednessTopical corticosteroidsRosaceaTSDFTelengiectasesRed skin syndromePerioral dermatitisMalar rashAbuseMisuse

Pimecrolimus has been approved for more than five years for the treatment of atopic dermatitis in Germany. An important difference in the safety profile of this drug compared with topical corticosteroids is the lack of potential side effects which are often observed upon prolonged use of topical corticosteroids (skin atrophy, steroid-induced rosacea or perioral dermatitis). Even after prolonged use in sensitive skin areas, no tolerance to this drug is induced, in contrast to that seen with topical corticosteroids. The most common side effect of pimecrolimus is burning. Placebo-controlled studies suggest that pimecrolimus is associated with a slightly increased incidence of herpes simplex infections. Compared with topical corticosteroids, pimecrolimus does not increase the overall incidence of skin infections (including recurrent herpes simplex infections). So far, clinical studies with pimecrolimus have not shown any evidence of an increased risk of malignancy. The analysis of spontaneously reported adverse events has also not shown any evidence of malignancy caused by pimecrolimus. This corresponds with the results of a case-control study from a large U.S. database. According to the German guidelines on atopic dermatitis, topical calcineurin inhibitors are indicated when topical corticosteroids are not indicated or when an anticipated lengthy treatment course would lead to inevitable side effects. On sensitive areas such as face, intertriginous regions and scalp, they are preferred as first-line choice over topical corticosteroids

Topical corticosteroids in atopic dermatitis and the risk of glaucoma and cataracts