Study of Clinical Profile of Patients Presenting with Topical Steroid-Induced Facial Dermatosis to a Tertiary Care Hospital

A Descriptive Study of Patients Presenting With Topical Steroid Damaged/Dependent Face (TSDF) to a Tertiary Care Center in Northern India

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.

Dermoscopic Distinction of Tinea Incognito on the Face and Topical Steroid Damaged Face: A Cross-Sectional Study in Skin of Color

Background

Dermatophytosis is widespread in India due to recalcitrant and resistant infection. Tinea incognito (TI) is modified dermatophytosis due to the inadvertent use of topical steroids (TS). Similarly, topical steroid-damaged face (TSDF) is caused by prolonged use of TS. Distinction of TI and TSDF is difficult when the face is affected. Dermoscopy can assist in the differentiation of both by revealing characteristic features. We evaluated the dermoscopic features in TI affecting the face and TSDF.

Aims and Objectives

To evaluate the clinical and dermoscopic features of TI affecting the face and TSDF. To observe the involvement of eyelids in TI as opposed to TSDF.

Materials and Methods

The study was conducted in a tertiary hospital after obtaining ethical clearance and informed consent. Patients with signs of TI or TSDF were enrolled and demographic data were collected. Patients who had applied TS/combination creams were included. A handheld dermoscope with 10x magnification was used. A potassium hydroxide mount was used to confirm the diagnosis of TI.

Results

Out of 80 patients, 27 males and 53 females were present. The mean duration of application was 8.25 ± 7 months. Clinical features were pruritus, erythema, scaling, and burning sensation. Eyelid involvement was noted in TI while it was spared in TSDF. On dermoscopy, morphological features were predominant in TI whereas vascular structures were found in TSDF in addition to white rosettes.

Conclusion

Dermoscopy distinguishes TI from TSDF comprehensively by demonstrating definitive features. In addition, the involvement of the eyelid is an excellent clinical sign of TI.

Topical Steroid Damaged Face - A Dermascopic Analysis

Background and Objectives

Dermoscopy particularly could be helpful in patients with steroid damaged face to assess and look for the damage caused by the steroid creams as also in cases where the patient provides improper history.

Materials and Methods

Patients attending to dermatology OPD with suspected/diagnosed TSDF between the ages of 18 and 60 years were enrolled and assessed on the basis of age, gender, residence, duration, potency, brand of application topical steroid creams, clinical and dermoscopic features.

Results

Majority abusing the topical steroid creams were females (n-14) with mean age with SD of 34 ± 11 and were from rural areas (57.8%). Red raised lesions were the most common clinical presentation (n-15) with telangiectasias as the most common dermoscopic feature (n-26). Triple combination creams containing hydroquinone 2%, tretinoin 0.025%, and 0.1% mometasone were on the top of the list (n-20).

Conclusion

In this study, the importance of dermoscopy in assessing the features of topical steroid damaged face and preventing further damage is highlighted. Various factors causing topical steroid creams misuse and the easy availability of the creams is to be kept on check.

Obsession to fairness and topical steroid induced acne: A situation analysis of patients presenting in dermatology clinic at a private hospital in Karachi

Objective

To determine the frequency of acne and other relevant side effects as well as the pattern of topical steroid and fairness cream use among patients presenting with steroid and fairness cream use at dermatology OPD in a tertiary care private hospital in Karachi.

Methods

A cross-sectional survey was conducted from April, 2020 to December, 2020 in a private tertiary care hospital in Karachi. In total, 226 patients with a positive history of topical steroids and/or fairness creams use in the past six months were included in the study. Information was collected about sociodemographic characteristics; topical corticosteroid uses while clinical examination of facial skin was performed by a dermatologist. Data were analyzed using SPSS version-19.

Results

The median age of study participants was 26 years with an interquartile range of 10 years. This frequency of corticosteroid induced acne was highest i.e., 83.6% (n=189) followed facial erythema and telangiectasia i.e., 50.9% (n=115) 47.8% (n=108) respectively. The estimated median duration of using topical steroids or fairness creams or both was six months with an IQR of four months. The study found statistically significant differences in the reasons of using topical corticosteroids or fairness creams on the face on the basis of differences in the level of education and marital status.

Conclusion

In Karachi, both, men and women are equally obsessed with fair skin tone and use topical steroids and fairness cream. The use of corticosteroid or fairness cream-induced facial acne is alarmingly high among patients presenting in a dermatology clinic in Karachi.

Topical Steroid Damaged Face: A Cross-Sectional Study from Saudi Arabia

Corticosteroids are one of the anti-inflammatory drugs that are used widely by dermatologists. Significant local adverse effects can happen if topical corticosteroids (TCs) are used incorrectly. This study aimed to assess the prevalence of facial TCs misuse and its adverse effects. This was cross-sectional research: a self-reported questionnaire was distributed among a population of Saudi Arabians aged 16 years and above who were using TCs consecutively. Statistical analysis was performed using SPSS version 26. A total of 611 participants were enrolled in the survey: 401 (65.6%) were university graduates, while 187 (30.6%) were below high school level of education. The number of participants using TCs was 279 (45.7%), while 332 (54.3%) did not use steroids topically. The most used TCs were Mometasone furoate 0.1% cream (18.2%), followed by Fusidic acid/Betamethasone cream (16.7%). A total of 46 reported facial TCs’ side effects. Peeling (52.2%) was the most reported side effect, followed by redness (41.3%). In conclusion, the use of facial TCs among the Saudi population is not uncommon (16.5%). A large population are not aware of the side effects of the unsupervised use of TCs. An effort should be made to increase awareness of the adverse effects of TCs.

Steroid Phobia: Is There a Basis? A Review of Topical Steroid Safety, Addiction and Withdrawal

There is a growing concern amongst patients about topical corticosteroid (TCS) side effects, with increasing discussion of topical steroid addiction (TSA) and topical steroid withdrawal (TSW) particularly on social media platforms. However, the acceptance of TSA/TSW as a distinct condition remains controversial within the dermatological community. We conducted a literature search using PubMed, MEDLINE, Cochrane Library, Google Scholar, Embase and Web of Science to identify original articles addressing TSA/TSW. We described the definition and reported clinical features of TSA/TSW including its classification into erythemato-edematous and papulopustular subtype. To assess the validity of TSA/TSW, we summarised and objectively appraised the postulated mechanisms for this condition, including tachyphylaxis, dysregulation of glucocorticoid receptors, rebound vasodilation and impaired skin barrier leading to a cytokine cascade. Understanding the evidence including its limitations and uncertainties highlights areas for future research and helps medical practitioners better counsel and provide care to patients who may be experiencing or who have concerns about TSA/TSW.

Dermoscopy of topical steroid-dependent or damaged face: A cross-sectional study

BACKGROUND

Topical corticosteroid (TCS) abuse is rampant and results in steroid addiction labeled as topical steroid-dependent or damaged face (TSDF). Indian market is replete with triple combination creams containing TCS sold as over-the-counter products at low cost, luring people to use them without prescription. The resultant damage if detected late is irreversible and difficult to treat. Dermoscopy can help in the early identification of features of TSDF at a preclinical stage resulting in better prognosis. However, the literature on the same is limited.

AIMS

This study is undertaken to characterize dermoscopic features of TSDF and to correlate them with potency and duration of application of the TCS.

METHODS

One hundred and thirty-two patients aged 18 years or above, with clinical symptoms and signs suggestive of TSDF and with history of application of TCS on the face for a period of more than one month, were enrolled in the study. Their demographic details, clinical features, and dermoscopy findings were recorded using a predesigned structured format. Comparison of dermoscopic findings with clinical examination, gender, potency of TCS, and duration of TCS use was done using Chi-square test, Fisher's exact test, and one-tailed Z-test.

RESULTS

Mean age of the patients was 31.7 ± 8.1 years. Male to female ratio was 2:9. Sixty-nine (52.3%) patients abused TCS for more than one year. Clinical findings noted in the patients were erythema (81.1%), hyperpigmentation (80.3%), and hypertrichosis (68.2%). The most common dermoscopy findings seen were brown globules (96.2%), red diffuse areas (92.4%), vessels (87.1%), white structureless areas (86.4%), and hypertrichosis (80.3%). Red diffuse areas, vessels, brown globules, white structureless areas, and white hair were observed in a statistically higher proportion of cases dermoscopically. Y-shaped vessels and brown globules were seen in significantly higher number of patients, using TCS for more than three months and in those continuing it beyond six months, polygonal vessels were predominant.

LIMITATIONS

Lack of histopathological correlation is the limitation of our study. Furthermore, brown globules seen in 96.2% patients of TSDF on dermoscopy may have been over-estimated and not always signify TSDF; instead, it could represent melasma for which patient applied TCS.

CONCLUSION

Dermoscopy in TSDF can help dermatologists in a multitude of ways from confirming the diagnosis to differentiating from other causes of red face and predicting the approximate duration of TCS abuse.

Topical corticosteroid withdrawal ('steroid addiction'): an update of a systematic review

BACKGROUND

Topical corticosteroid withdrawal is an entity associated with chronic steroid use and misuse that has not been fully described.

OBJECTIVE

To further characterize this entity, elucidate relevant clinical features, and investigate possible treatments we provided an update to a systematic review done in 2015.

METHODS

We searched Ovid Medline, Pubmed, and Cochrane library for terms related to topical corticosteroid withdrawal from April 2014 to September 2020.

RESULTS

This entity usually occurs after prolonged use of moderate- to high-intensity topical steroid usage usually on the face. It is most common in women and many patients present due to improper use such as for cosmetic reasons. Symptoms include erythema, itchiness, and burning; secondary lesions are common scales.

LIMITATIONS

Due to the paucity of available study, we elected to include all articles found which led to limitations being lack of heterogeneity, diversity of outcome measures reported, and a higher risk of bias in some included studies.

CONCLUSION

Topical corticosteroid withdrawal should be suspected in patients presenting with prolonged usage, erythema, and burning or itch. Patient education and follow up is important to address improper usage. Future studies should focus on comparison group studies to investigate treatment and risk factors.