Jerome Z. Litt
Potent topical fluorinated corticosteroids are used for the relief of the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses. Fluorinated corticosteroids exert their effect through anti-inflammatory, antipruritic and vasoconstrictive actions. These preparations are commonly prescribed for psoriasis, seborrheic dermatitis, lichen planus, lichen simplex chronicus (neuro-dermatitis), atopic dermatitis and a host of other pruritic papulosquamous eruptions.
Topical fluorinated corticosteroids are associated with a significant incidence of adverse local and systemic side effects. These preparations are absorbed from normal, intact skin. Absorption is substantially increased by occlusive dressings, inflammatory skin disorders and other cutaneous diseases. Once absorbed through the skin, corticosteroids are metabolized in the liver and excreted by the kidneys.
Adverse local effects can occur when potent fluorinated corticosteroids are used for long periods on susceptible areas such as the face, flexural creases, areas where the skin is thin and areas under occlusive dressings or where natural occlusion occurs (Table 1).
Adverse Effects of Topical Fluorinated
Maceration of the skin
Rosacea-like rash (“iatrosacea”)
A common steroid-induced skin complication is “iatrosacea,” a perioral, rosacea-like dermatitis characterized by erythema, papules, pustules, telangiectases and, occasionally, atrophy. Fluorinated skin preparations can also cause atrophic changes. Topical fluorinated steroids inhibit skin collagen synthesis by fibroblasts, and this impaired collagen synthesis can result in dermal atrophy and striae formation. These changes are especially likely to occur in intertriginous areas and in areas where occlusive dressings have been used.[5-9]
Occasionally, gluteal granulomas can occur as a result of steroid use. These granulomas have been related to the use of fluorinated steroids in conjunction with plastic pants in infants. Characterized by firm, reddish-blue or purplish nodules on the buttocks, the granulomas develop at points of maximum contact with a diaper or plastic pants.
Use of fluorinated corticosteroids can also obscure the clinical features of certain dermatoses, such as scabies, and fungal and yeast infections. Pustular psoriasis can sometimes occur following steroid withdrawal when steroids have been used on psoriatic skin. Acneiform eruptions can result from prolonged treatment with locally applied corticosteroids.” Purpura may develop over the forearms and upper arms in older patients and is a result of the application of a corticosteroid preparation on skin that is already somewhat thinned secondary to the aging process and sun exposure. Additional adverse effects that can occur with these medications include leukoderma, folliculitis, hypertrichosis, miliaria, secondary infection, maceration of the skin and allergic eczematous contact dermatitis.[17,18]
With excessive and prolonged use of topical fluorinated corticosteroids, systemic absorption can result in hyperglycemia and manifestations of Cushing’s syndrome in some patients.[19-21] Systemic toxicity is more likely with use of higher potency fluorinated corticosteroids, particularly when occlusive dressings are used and when these agents are applied over large areas of the body.
Because children have a larger skin surface area in proportion to body weight and because their skin is much thinner than adults’ skin, children can absorb proportionally larger amounts of topical corticosteroids. Thus, they are more susceptible to systemic toxicity and adrenal suppression, which may interfere with normal growth and development.
Iatrosacea is an uncommonly discussed rosacea-like dermatitis of the face that can develop with the use of topical fluorinated corticosteroid preparations. Eight cases of iatrosacea are briefly discussed below.
A nine-month-old male infant presented with erythematous patches and papules on his cheeks and chin of two months’ duration (Figure 1). During this period he had been treated with topical triamcinolone acetonide cream (Aristocort A). The infant was started on oral erythromycin therapy at a dosage of 250 mg once daily. Treatment also included use of a soap substitute bar and twice-daily application of a paste containing 10 mL of Burow’s solution, 20 g of Aquaphor and 30 g of zinc oxide paste. He improved steadily and was free of lesions after six weeks.
A 30-year-old woman presented with erythematous and edematous papules and pustules on her cheeks and malar eminences (Figure 2). She had been treated for sun allergy with fluocinonide cream (Lidex) for over one year. She was started on a regimen of oral tetracycline, zinc oxide ointment and a soap substitute bar (Lowila Cake) for three months. She had markedly improved by the end of the treatment period.
A 27-year-old woman presented with a bright-red, patchy eruption of papules and pustules on her cheeks (Figure 3). She also had papules on her chin and numerous telangiectases. She had received four months of treatment with betamethasone valerate cream (Valisone) for a facial rash. Oral tetracycline and mild sulfur lotion were prescribed, and the lesions cleared in about six weeks.
A 65-year-old woman presented with a diffuse, erythematous, papular eruption on her cheeks, chin, nose and forehead of several months’ duration (Figure 4). She had been treated for several months with betamethasone valerate ointment (Valisone) for a facial rash. Oral tetracycline, zinc paste and a mild soap were prescribed, and she improved after four months of treatment.
A 29-year-old woman presented with a bright-red, diffuse, papular eruption covering her chin and most of her upper lip area (Figure 5). She had been treated over a number of weeks with betamethasone benzoate lotion (Uticort) for a nonspecific facial eruption. Six weeks after she was started on treatment with oral tetracycline, zinc oxide ointment and a soap substitute bar, marked improvement was evident.
A 16-year-old woman presented with an erythematous, papular and scaly eruption on her cheeks and paranasal areas (Figure 6). For more than a year she had been treated with betamethasone valerate cream (Valisone) for a facial rash. She was treated with oral tetracycline, milk compresses and zinc ointment, and was greatly improved after six weeks.
A 22-year-old woman presented with a sharply marginated, erythematous and edematous, papular and pustular eruption on her chin and perioral area (Figure 7). She had received treatment with fluocinonide gel (Lidex) for three months for a rash presumably due to irritation from her husband’s beard. With treatment consisting of oral tetracycline, zinc ointment and a soap substitute bar, the lesions slowly resolved. After five months, resolution was almost complete.
An 80-year-old woman presented with an erythematous, papular and pustular eruption covering almost all of her face (Figure 8). She had been treated with betamethasone dipropionate cream (Diprosone) for an apparent angular stomatitis (perleche). She applied the cream regularly three times daily for one year. The rash became progressively worse and began to spread from her mouth angles to the rest of her face. She was placed on oral tetracycline and milk compresses three times daily. After five and one-half months of treatment, she had greatly improved.
These patients ranged in age from nine months to 80 years. All but one of them were women. The duration of the eruptions, before treatment, varied from two months to two years. All of the patients eventually improved after a period of treatment ranging from three weeks to seven months. The adult patients received oral tetracycline in doses ranging from 500 mg to 1,000 mg daily, depending on the extent and severity of the initial eruption. During the course of treatment, the dose of tetracycline was reduced in proportion to the rate of improvement. Various local, nonsteroidal remedies were used. Metronidazole topical gel (Metrogel) has also been used successfully in patients with this condition.
The regular use of topical fluorinated corticosteroids on the face can produce a distinctive rosacea-like eruption consisting of persistent erythema, papules, pustules and telangiectases. To prevent steroidinduced rosacea, physicians should not prescribe fluorinated corticosteroids for minor eruptions, nor should fluorinated corticosteroids be prescribed for long-term use on the face. Use of fluorinated steroids on the face should be avoided.
REFERENCES[1.] Leyden JJ, Thew M, Kligman AM. Steroid rosacea. Arch Dermatol 1974;110:619-22. [2.] Hogan DJ, Epstein JD, Lane PR. Perioral dermatitis: an uncommon condition? Can Med Assoc J 1986;134:1025-8. [3.] Hogan DJ, Rooney ME. Facial telangiectasia associated with long-term application of a topical corticosteroid to the scalp. J Am Acad Dermatol 1989;20:1129-30. [4.] Coskey RJ. Perioral dermatitis. Cutis 1984;34:55-6,58. [5.] Chernosky M, Knox J. Atrophic striae after occlusive corticosteroid therapy. Arch Dermatol 1964;90:15-9. [6.] Bondi EE, Kligman AM. Adverse effects of topical steroids. Prog Dermatol 1980;14:1-4. [7.] Grice K. Tinea of the hand and forearm. Betamethasone valerate atrophy. Proc R Soc Med 1966;59:254-5. [8.] Stevanovic DV. Corticosteroid-induced atrophy of the skin with telangiectasia. A clinical and experimental study. Br J Dermatol 1972;87:548-56. [9.] Epstein NN, Epstein WL, Epstein JH. Atrophic striae in patients with inguinal intertrigo. Arch Dermatol 1963;87:450-7. [10.] Uyeda K, Nakayasu K, Takaishi Y, Sotomatsu S. Kaposi sarcoma-like granuloma on diaper dermatitis. A report of five cases. Arch Dermatol 1973;107:605-7. [11.] Hamada T. Granuloma intertriginosum infantum (granuloma glutaeale infantum) [Letter]. Arch Dermatol 1975;111:1072-3. [12.] Bonifazi E, Garofalo L, Lospalluti M, Scardigno A, Coviello C, Meneghini CL. Granuloma gluteale infantum with atrophic scars: clinical and histological observations in eleven cases. Clin Exp Dermatol 1981;6:23-9. [13.] Blank H. Topical corticosteroid therapy – a round table discussion. Cutis 1979;24:633-8. [14.] Boxley JD, Dawber RP, Summerly R. Generalized pustular psoriasis on withdrawal of clobetasol propionate ointment. BMJ 1975;2: 255-6. [15.] Fulton JE, Kligman AM. Aggravation of acne vulgaris by topical application of corticosteroids under occlusion. Cutis 1968;4:1106-8. [16.] Kestel JL Jr. Hypopigmentation following the use of Cordran tape. Arch Dermatol 1971;103:460. [17.] Coskey RJ. Contact dermatitis due to multiple corticosteroid creams. Arch Dermatol 1978;114: 115-7. [18.] Forstrom L, Lassus A, Salde L, Niemi KM. Allergic contact eczema from topical corticosteroids. Contact Dermatitis 1982;8:128-33. [19.] Leu F. Complications from prolonged topical steroid therapy [Letter]. J Am Acad Dermatol 1983;8:425-6. [20.] Kelly A, Nelson K, Goodwin M, McCluggage J. latrogenic Cushing’s syndrome. BMJ 1972;4:114. [21.] Staughton RC, August PJ. Cushing’s syndrome and pituitary-adrenal suppression due to clobetasol propionate. BMJ 1975;2:419-21.
JEROME Z. LITT, m.d. is assistant clinical professor of dermatology at Case Western Reserve University School of Medicine, Cleveland. A graduate of Chicago Medical School, Dr. Litt completed a residency in dermatology at Kings County Hospital, Brooklyn, N.Y., and a fellowship at the Skin and Cancer Hospital, New York.
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