2014.1-1.Corticosteroid

Figure 1. Erythema of central face – steroid rosacea. Figure 2. Acneform eruption following steroid application for pigmentation of face. Figure 3. Steroid dependent face (SDF) showing diffuse erythema and scaling. Figure 4. Steroid induced pigmented monomorphic acne.

Results

Figure 5. Duration of steroid application.

Figure 6. Reason for steroid application.

Figure 7. Type of skin lesion.

                  Table I. Age distribution of patients.

                  Table II. Potency of steroid applied and number of patients.

Discussion

Ever since the invention, topical steroids are misused both by prescribing doctor and patient themselves, as it gives instant relief to signs and symptoms [1]. Face is the commonest site of such misuse as its effect is cosmetically appreciable and it is most often used as fairness cream also [2]. 23% of our patient were using it for fairness effect and 10% continued to use it for the same reason. Different names are given to steroid abuse lesions on face, most often called as steroid rosacea [3]. Red face syndrome [4] and SDF [1] also refers to same effect. Sequence events that lead to steroid abuse is as follows-doctor will prescribe moderately potent steroid to get benefit and avoid side effects of potent steroid, (like in our study and by Rathy SK et al [4] where it was betamethasone valerate) for some dermatosis of face, impressed by response, patient continues to use it and often refer to friends also. Saraswat et all observed use of potent and super potent steroids in majority [1]. Effect of steroid reduces due to tachyphylaxis [5] and patient is forced to use potent steroid and cycle continues. On stopping the medication there is rebound erythema and scaling which occur due to release of cytokines, accumulation of nitric oxide causing vasodilatation and doubtful role of demodex mites [6]. Acne form eruptions are also commonly observed following TCS application. Our study showed acne form lesions as commonest side effect. Bhat YJ et al [3] observed more rosasea than acne. It is interesting to observe that majority of our patients used steroid for treatment of various forms of inflammatory acne. Initially they had relief and on continued use developed monomorphic pigmented papules which was the commonest lesion observed in our study. Other common side effects like telengectasia, hypertrichosis, infections were less commonly observed in our study as in other studies [7]. Systemic side effects like adrenal axis suppression, diabetes, hypertension etc following topical application are reported only if applied to larger areas as in other diseases [8], are rare with use on face. Allergic dermatitis to TCS are reported [9]. None of our patients had allergic reaction to TCS. Most of time allergic response is to base used and SDF which manifests as erythema and scaling is mistaken as allergy [10]. Perioral dermatitis an entity initially described following use of fluorinated steroid on face [11], and reported in studies [12], was not seen in our study. Management of patient with SDF include initial careful education about dependency and counselling as to recurrence of lesions on stoppage of steroids. Slow tapering by decreasing frequency or switching to lower potent steroid is to be done. Oral tetracyclines are proved to be effective [13]. Other drugs like low dose doxycycline and azithromycin also have shown to be effective [3]. Recently topical tacrolimus is reported to be effective [14]. Studies show effectives of pimicrolimus also similar to tacrolimus [15,16]. There is always a doubt as to which steroid is safe for face [17], in fact no steroid is safe for face, and to be prescribed only if specifically indicated for shorter duration. And it is very essential to educate patient about side effects and dependency in order to prevent the consequences of abuse. This kind of awareness among doctors and patient is highly essential as magnitude of problem is high.