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Review Article

Side-effects of topical steroids: A long overdue

revisit
Arijit Coondoo, Meghana Phiske1, Shyam Verma2, Koushik Lahiri3

Department of ABSTRACT
Dermatology, KPC
Medical College, The introduction of topical steroids (TS) of varying potency have rendered the therapy of inflammatory cutaneous
Kolkata, 1Lokmanya disorders more effective and less time-consuming. However the usefulness of these has become a double edged
Tilak Muncipal Medical sword with constantly rising instances of abuse and misuse leading to serious local, systemic and psychological
College and General side effects. These side effects occur more with TS of higher potency and on particular areas of the body like
Hospital, Sion, Mumbai,
face and genitalia.The article reviews the side effects of TS with special mention about peadiatric age group,
Maharashtra, 2Consultant
also includes the measures for preventing the side effects.
Dermatologist, Vadodara,
Gujarat, 3Consultant
Dermatologist, Appollo Key words: Local systemic, side effects, topical steroids
Gleneagles Hospital and
Wizderm, Kolkata, India
INTRODUCTION when potent TCs are used on their softer skin
with enhanced capacity for absorption as also the
The introduction of topical corticosteroids (TC) issue of weight versus body surface.[3] TCs are
by Sulzberger and Witten in 1952 is considered the choice of therapy in atopic children however,
to be the most significant landmark in the history steroid-phobia among parents of such children
of therapy of dermatological disorders.[1] This is now a well-documented phenomenon. At the
historical event was gradually, followed by the opposite end of the spectrum lies the danger
introduction of a large number of newer TC of steroid addiction. While TC addiction can
molecules of varying potency rendering the therapy manifest with features of TSDF, its withdrawal
of various inflammatory cutaneous disorders more is also accompanied by repeated flares of
effective and less time consuming. Although, it is photosensitivity, erythema, papules and pustules
this very usefulness of the drug which has become accompanied by intense itching and burning,
a double edged sword and made it vulnerable features of the so called “TSDF.” TC misuse
to now an alarming proportion with constantly has thus become almost an epidemic needing
Access this article online immediate attention from all quarters.
rising instances of abuse and misuse leading to
Website: www.idoj.in
serious local, systemic, and psychological side
DOI: 10.4103/2229-5178.142483 Side effects due to topical steroids (TS) are more
effects. Such misuse occurs more with TC of
Quick Response Code: prevalent than systemic reactions.
higher potency and on softer areas of the body
particularly the face and genitalia. The end-users
of TC are hapless patients. They tend to overuse The most common side effects are localized
TCs beyond the time limit set by clinicians by to sites of application. [4] The mechanisms
repeating prescriptions. Of more concern is responsible for their effectiveness are also
the mass use of TCs as fairness creams. Vast responsible for their adverse effects.[5]
sections of the Indian society have willingly or
Address for
unknowingly become victims to the craze of SIDE EFFECTS CAN BE DIVIDED
correspondence:
Arijit Coondo
beautification leading to a virtual epidemic of INTO
Department of monomorphic acne, steroid atrophy, steroid
Dermatology, KPC rosacea, telangiectasia, perioral dermatitis, Local side effects
Medical College, striae and other manifestations of a condition These tend to occur with prolonged treatment and
Kolkata, India. which has been collectively described as topical depend on potency of TS, its vehicle and site of
E-mail: steroid damaged facies (TSDF).[2] Children are application. The most common include atrophy,
acoondoo@gmail.com
particularly prone to develop systemic side effects striae, rosacea, perioral dermatitis, acne and

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Coondoo, et al.: Side effects of topical steroids

Table 1: In the infection column, put comma between Granuloma gluteale infantum and genital ulceration
Unwanted effects Clinical features Risk factors and mechanism
of topical steroids
Epidermal effects Epidermal thinning Decrease in mean keratinocyte layer thickness
Flattening of the dermoepidermal convolutions
Decrease in epidermal kinetic activity
Melanocyte inhibition (vitiligo like condition) Intradermal steroid injections, steroids under occlusion
Dermal effects Striae Risk factors
Easy rupture on trauma Young age
Blot hemorrhage Potency of steroid
Stellate scars Use of occlusion
Prematurely aged skin appearance Location (face, neck, axilla, groin, upper inner thigh)
Decrease in ground substance and collagen synthesis
Combined Atrophy Dermal atrophy and loss of intercellular substance,
epidermal and Telangiectasia causing blood vessels to lose their surrounding dermal
dermal effects matrix
Striae
Purpura
Stellate pseudoscars
Ulceration
Easy bruising
Vascular effects Fixed vasodilatation
Rebound phenomenon
Perioral dermatitis
Rosacea
Facial erythema
Ocular effects Due to steroid eye drops
Glaucoma/cataract
Decreased healing of traumatic ulcers
Exacerbation of herpetic ulcers
Increased susceptibility to bacterial and fungal infections
Blindness (on prolonged use)
Few side effects due to topical steroids applied around eyes
Blindness due to glaucoma after long term steroid
application on face
Contact allergy Allergic or irritant contact dermatitis Risk factors
History of many positive patch test to nontopical
steroid allergen
Treatment resistant eczema
Leg ulcers
Stasis dermatitis
Perineal dermatitis
Infections Exacerbation or increased susceptibility to bacterial, viral and Chronic actinic dermatitis
fungal infections (e.g., Candidiasis, herpes or Demodex)
Folliculitis
Crusted scabies
Granuloma gluteale infantum, genital ulceration
Masking of microbial infections (tinea incognito) and
(tinea pseudoimbricata)
Effect on hair Hypertricosis (prevalant on face and ears)
Lanugo hair
Alopecia
Contd....

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Coondoo, et al.: Side effects of topical steroids

Table 1: Contd....
Unwanted effects Clinical features Risk factors and mechanism
of topical steroids
Vehicle related Stinging
effects Irritation
Folliculitis
Miliaria
Contact urticaria
Exacerbation of acne and rosacea
Allergic contact dermatitis
Pharmacologic Tachyphylaxis Risk factors
effects Patient noncompliance
Normal variance in disease severity that is unrelated
to therapy
Inability of steroids to completely clear the disease
Steroid rebound
Steroid addiction
Miscellaneous Acneiform eruption Comedone formation by rendering follicular
epithelium more responsive to comedogenesis
Increased concentration of free fatty acids in skin
surface lipids and increased numbers of bacteria in the
pilosebaceous duct
Miliaria
Urticaria
Delayed wound healing
Tachyphylaxis
Reactivation of Kaposi’s sarcoma
Alteration of fat distribution (Cushingoid appearance)
Hypopigmentation (common in dark skinned and reversible)
Hyperpigmentation
Rebound flare (psoriasis)
Milia Risk factors
Long term use
Old age

purpura. Hypertrichosis, pigment alteration, delayed wound include:

healing and exacerbation of skin infections are less frequent.[5] • Increased application of moderately potent TS
Table 1 lists the local side effects of TS with associated risk • Modest use of more potent derivatives
factors and mechanism. • Increase in the steroid penetration (increases HPA
suppression potential, especially in atopic children)
Systemic adverse effects • Use of TS under occlusion
Systemic adverse effects from TS have also been described • Use of higher concentrations of TS
and they are more likely to develop when highly potent TS are • Application of TS over large surface areas.
used for prolonged periods on thin skin (e.g. face) or on raw/
inflamed surfaces.[4,5] Betamethasone dipropionate and diflorasone diacetate have an
increased ability to suppress adrenal function. Around 14 g/week
SUPPRESSION OF THE HYPOTHALAMIC- of clobetasol propionate ointment may induce suppression in
PITUITARY-ADRENAL AXIS children, while 49 g/week of betamethasone dipropionate reduces
plasma cortisol levels. Temporary reversible suppression is seen
Hypothalamic-pituitary adrenal axis suppression is known to with 49 g of superpotent TS used for 2 weeks. Children and babies
occur with all TS. Factors responsible for HPA axis suppression have a high ratio of surface area to body volume hence are more

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Coondoo, et al.: Side effects of topical steroids

likely develop HPA axis due to systemic absorption. Iatrogenic in epidermis are evident following 3-14 days of treatment.
Cushing syndrome, corticosteroid-related Addison crises, growth Initially epidermis becomes thin due to reduction in epidermal
retardation and death are also reported. The reactivity of the HPA cell size, which reflects a decreased metabolic activity. After
axis can be assessed with the adrenocorticotropin hormone test. prolonged exposure there is a reduction in cell layers, that is,
Recovery is time-dependent and occurs spontaneously.[4,5,8] stratum granulosum disappears and stratum corneum becomes
thin. Synthesis of stratum corneum lipids and keratohyalin
Hyperglycemia and diabetes mellitus granules and formation of corneodesmosomes (required
Hypergylcemia and the unmasking of latent diabetes mellitus for structural integrity of stratum corneum) are suppressed.
can occur after prolonged application and high percutaneous Inhibition of the function of melanocytes may occur, giving rise
absorption of TS; also systemically absorbed TS may to localized hypopigmentation.[4,5]
precipitate or exacerbate hyperglycemia, especially in patients
with preexisting hepatic disease.[8] Topical steroids induce resorption of mucopolysaccharide
ground substance in the dermis. Repeated use in the same area
Mineralocorticoid effects causes epidermal thinning and changes in connective tissue
Topical steroids have minimal or no mineralocorticoid of dermis leading to lax, transparent, wrinkled and shiny skin
activities, but hydrocortisone and 9-a-fluoroprednisolone, have along with striae, fragility, hypopigmentation and prominence
measurable mineralocorticoid activity. Prolonged treatment of underlying veins. The loss of connective tissue support for
may lead to edema and hypocalcemia.[8] Table 2 lists the rare dermal vasculature results in erythema, telangiectasia and
systemic adverse effects of TS. purpura.[4]

Degree of skin atrophy is influenced by age, body site, potency

Side effects due to intralesional steroids
and presence of occlusion. It is caused by suppressive action
Hypopigmentation and skin atrophy can occur when TS are
applied topically or injected locally. However, the mechanism on cell proliferation and inhibition of collagen synthesis.
by which hyopigmentation occurs is not clear. Linear extension Dermal atrophy is caused by decreased fibroblast growth and
of the hypopigmentation is due to lymphatic uptake of steroid reduced synthesis of collagen, acid mucopolysaccharides and
crystals. Venkatesan and Fangman demonstrated that stimulation of human dermal microvascular endothelial cells.
melanocytes are intact in steroid-induced hypopigmentation, Intertriginous areas are particularly susceptible due to thinner
which indicates that TS may impair melanocyte function. skin, increased moisture, elevated temperature and partial
Triamcinolone is more likely to cause depigmentation due occlusion provided by the skin in these sites.[8] The atrophy is
to its larger size, the higher tendency to aggregate and reversible on stoppage of TS, but the normalization may take
higher density. Hence for lesions close to the skin surface, months.[11]
especially in hyperpigmented patient triamcinolone should be
avoided, instead TS with smaller particles and less tendency Striae
to aggregate should be preferred.[10] Various side effects of Striae due to TS use need to be distinguished from those that
topical steroids are depicted in Figures 1-18. occur due to excessive weight gain and pregnancy.[8]

ATROPHY-THE COMMONEST SIDE Contact allergy

Contact hypersensitivity to TS may cause persistence or
EFFECT
worsening of skin diseases. It is rare, but its risk increases with
Skin atrophy is the commonest side effect, reported to be prolonged exposure. Nonfluorinated TS (e.g, hydrocortisone
caused by all topical TS.   Epstein et al. first reported it from use hydrocortisone-17-butyrate, and budesonide) result in a higher
of topical triamcinolone acetonide.[8] Atrophic changes can affect prevalence of contact allergy in comparison with fluorinated
both epidermis and dermis. Microscopic degenerative changes compounds. Binding to the amino acid arginine is probably
required for development of contact allergy.[8]
Table 2: Rare systemic adverse effects of topical
steroids[8] Contact sensitivity can develop not only to constituents
Ocular Cataract (posterior subcapsular), glaucoma
(e.g. lanolin, preservatives such as parabens and antibiotics)
of the preparation, but also to the steroid molecule. Sensitivity
Endocrine Cushing disease, moon face, centripetal
obesity, buffalo hump, striae to more than one TS is common. Risk factors for development
Metabolic Glucose intolerance, reduced bone of contact sensitivity include history of multiple patch test
mineral density, osteopathy, adrenocortical positivity to non-TS allergen, treatment resistant eczema, leg
suppression, decreased growth rate ulcers, stasis dermatitis, perineal dermatitis and chronic actinic
Electrolyte balance Edema, hypocalcemia, hypertension dermatitis. It presents as chronic dermatitis not responding to

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Coondoo, et al.: Side effects of topical steroids

locally applied steroids or rarely, as acute eczema, urticaria, initially controlled with low potency TS, but lesions may
acute local edema, immediate-type reaction, or id eruption like reappear and require continued use of higher potency TS.[8]
spread over the body.[4-6]
Perioral dermatitis
Infections Perioral dermatitis occurs in females on the face and is
Mucocutaneous infections (tinea versicolor, onychomycosis caused by long term use of potent TS on face. It presents as
due to Trichophyton and Candida species, dermatophytosis) follicular papules and pustules on an erythematous base seen
are common during treatment with TS, occurring early in the in a perioral distribution, with sparing of skin adjacent to the
therapy. The incidence varies between 16% and 43%. When vermilion border. It is also seen in men and children.[8]
dermatophyte infections are treated with TS, the symptoms
and signs improve transiently, giving rise to tinea incognito. Hypertrichosis
TS suppress the normal cutaneous immune response to Steroids promote vellus hair growth by unknown mechanism.
dermatophytes leading to enchantment of fungal infections. An Local and disseminated hypertrichosis due to TS is rare, seen
immune mediated phenomenon called “tinea pseudoimbricata” commonly with systemic steroids. Even months after withdrawal
is a particular type of tinea incognito which has been described of TS the darker hairs may persist.[8]
by one of the authors.[12] Pruritus in scabies improves by TS
but infestation persists unless scabicidal treatment is given.
Hyper/hypopigmentation
Granuloma gluteale infantum a persistent reddish-purple,
Hypopigmentation after topical use is quite common, but not
granulomatous, papulonodular eruption seen on buttocks,
noticed frequently in very light skinned individuals. People with
thighs or inguinal fold in children, is a well-known consequence
Type IV to VI are particularly affected. TS probably interfere
of diaper dermatitis being treated with TS, caused by impairment
with the melanin synthesis by smaller melanocytes, causing
of immune response to Candida by TS.[4]
patchy areas of hypopigmentation which are reversible
after discontinuation of steroids. Hyperpigmentation after
Similar effects on mitigation or prolongation of herpes simplex,
intralesional steroids has been well-documented.[8]
molluscum contagiosum and scabies infection have also been
reported; hence TS should not be used in presence of these
infections. TS also facilitate proliferation of Propionibacterium acnes Purpura, stellate pseudoscars, and ulcerations
and Demodex folliculoroum leading to acne-rosacea like condition. These develop after severe steroid induced dermal atrophy and
Reactivation of Kaposi sarcoma has also been reported.[8,9] loss of intercellular substance, causing blood vessels to lose
their dermal matrix support. The resulting fragility of dermal
vessels leads to purpuric, irregularly shaped, hypopigmented,
Acneiform eruptions
depressed pseudoscars over extremities. Continued misuse
Systemic corticosteroid therapy, in some cases intravenous
of TS can also lead to ulceration.[8]
or inhaled TS are known to induce acneiform lesions. The
eruption consists of small and uniformly sized (monomorphic)
inflammatory papules and pustules with few or no comedones, Tachyphylaxis
located predominantly on trunk and extremities, with less Tachyphylaxis is characterized by decreasing efficacy of TS
involvement of the face. In the case of inhaled steroids, lesions during continued treatment. It occurs commonly in psoriasis
occur in and around nose or mouth. Anti-inflammatory effects of patients. [9] It may reflect patient noncompliance, normal
TS may initially suppress inflammatory lesions and erythema, variance in disease severity unrelated to therapy, or inability
but flare-ups occur on stopping TS. The eruption subsequently of TS to completely clear the disease. Withdrawal of TS
resolves after discontinuation of the TS. is followed by a disease flare. As the tissue becomes less
sensitive (tachyphylaxis), increasingly potent preparations
Topical steroids induce comedone formation by rendering are required to achieve comparable effects, leading to more
follicular epithelium more responsive to comedogenesis. severe side effects.[8] Tachyphylaxis can be quantified by
They also lead to increased concentration of free fatty acids vasoconstrictor assay and inhibition of fibroblast proliferation.[4,5]
in skin surface lipids and increased numbers of bacteria in the
pilosebaceous duct. Free fatty acids, formed in pilosebaceous Rebound phenomenon
ducts by breakdown of triglycerides in the sebaceous secretion, Withdrawal of potent TS applied to the extensive area of
may contribute to comedogenesis.[13,14] psoriasis for a prolonged period may result in a relapse or
a papulopustular flare and may even precipitate unstable or
Rosacea severe generalized pustular psoriasis. This is especially likely
Topical steroids induced rosacea is seen in middle-aged when steroids are used in large quantities or applied under
woman, presenting with papules and pustules. These are occlusion. vascular effect of TS is vasoconstriction of superficial

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Coondoo, et al.: Side effects of topical steroids

small vessels, followed by rebound vasodilatation which may as compared to other body sites. Blindness due to glaucoma
become fixed after prolonged treatment and may be more following extended TS use on the face is reported.[8]
conspicuous, as a result, of dermal and epidermal atrophy.
Similarly, abrupt withdrawal can cause eczema flares.[4,5] Effect on wound healing
Topical steroids have demonstrated to impair wound healing
Steroid addiction and re-epithelialization in animal and human models.[5] The
Steroid addiction is known to occur after inadvertent application effects are on keratinocytes (epidermal atrophy, delayed
of potent TS usually on the face.[8] Patients with steroid addiction reepithelialization), fibroblasts (reduced collagen and
have acne, rosacea, perioral dermatitis, or telangiectasia and ground substance), vascular connective tissue support and
continue its use, fearing that there may be flare of their condition on angiogenesis (delayed granulation tissue formation).[8]
steroid withdrawal. Three phases have been described: (1) Initial
treatment improves pustulation, pruritus, erythema and scaling; (2) Alterations in skin elasticity and mechanical properties
with continued use, local immunosuppression increases microbial Topical steroids are known to decrease skin elasticity. This
growth and (3) on treatment withdrawal, rebound flares of itching, can be assessed by pulling the skin and observing incomplete
redness, postulation and scaling are seen.[5] “Red burning skin retraction on mechanical stress cessation.[8]
syndrome” may be the presentation in some cases.[8]
Influence of sun and aging
TOPICAL STEROID-DEPENDENT FACE Skin aging pathophysiology is similar to the one that follows
TS application. Marked skin thickness decrease, especially in
Misuse of TS on the face is seen all over India and its light-exposed areas and delayed skin recovery are reported.[8]
incidence appears to be increasing rapidly. TSDF has also
been described under various names like steroid addiction,
dermatitis rosaceaformis steroidica and red face syndrome.
In this condition after long term application of TS on the
face, there is severe rebound erythema, burning and scaling
on the face on attempting to stop the application of TS. [2]

Ocular side effects

Side effects caused by steroid eye drops are listed in Table 1.
But there are few reports of such ocular complications due to
TS.[5,6] Use of TS around eyes can rarely lead to glaucoma
as penetration of TS is 300 times greater through the eyelid

a b Figure 2: Comedonal acne Courtesy

Figure 1: (a) Comedonal acne Courtesy Dr. Koushik Lahiri, (b) Steroid
acne

a b
a b Figure 4: (a) Marked facial erythema on a background of acne (b)
Figure 3: (a) Mild infantile acne Courtesy Dr. Shyam Verma, Nodular acne Courtesy
(b) Comedonal and papular acne

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Coondoo, et al.: Side effects of topical steroids

a b
a b
Figure 6: (a) Nodular acne with hemorrhagic crusting and pustulation
Figure 5: (a) Nodular ance with crusting (b) Rosacea Courtesy Dr. Koushik Lahiri, (b) Telangiectasia overlying vitiligo patch
on eyelid

a b
Figure 7: (a) Nodular acne with overlying hyperpigmented keratotoc a b
papules (b) Telangectasia with hypopigmentation over genitals
Figure 8: (a) Facial erythema Courtesy Dr. Kaushik Lahiri,
(b) Telangiectasia with bacterial infection

a b
Figure 9: (a) Thinning of skin on dorsal aspect of hands with visibility a b
of vessels, (b) Tinea incognito

Epidermal barrier disturbance

Topical steroids application can lead to subtle changes in
the epidermal barrier as observed by decreased formation of
lipid lamellar bodies and delayed barrier recovery. This effect,
theoretically may worsen barrier impairment in atopic dermatitis
c
and psoriasis, but it seems to be outweighed by reducing
Figure 10: (a) Striae rubra with associated hypopigmentation (b)
inflammation and permitting barrier repair.[8]
Perioral dermatitis with background erythema and mild acne (c)
Perioral dermatitis with background erythema and mild acne
Vehicle related effects
Vehicle of TS can potentiate the side effects of TS and cause so they are likely to be susceptible to side effects of TS, hence
local side effects of its own. Table 3 lists the components of they should be avoided in children or, if necessary, used with
the vehicle that cause side effect.[6] care and for short periods. Food and Drug Administrations center
for drug evaluations and research have reported TS side effects
EFFECTS OF TOPICAL STEROIDS IN similar to those seen in adults. Some side effects not reported
PEDIATRIC PATIENTs in adults but seen in children include local irritation, mood
change, gynecomastia, genital hypertrichosis and staphylococcal
British National Formulary states that skin of children is sensitive infection.

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Coondoo, et al.: Side effects of topical steroids

PREVENTION OF ADVERSE EFFECTS molecules.[6] This may only be the tip of the iceberg. Since
a large number of TCs are sold as OTC product, the actual
Guidelines regarding TS use are available to prevent their sales figure might be much more.[15] However, the main onus
misuse. General measures to prevent TS induced side effects to curb this menace is on Government of India with its laxity
are mentioned in Table 4 while Table 5 mentions measures to in formulation, interpretation and implementation of laws
prevent site specific side effects.[8]

CONCLUSION

Topical corticosteroids misuse occurs at various levels.

The pharmaceuticals manufacture and promote unethical
combinations (e.g. “modified” Kligman’s regime). Of further
concern is the unrestricted over the counter (OTC) sale of
TCs of all potencies though many of them are Schedule
H drugs. The official IMS Health figures for sale of TCs in
a b
2013 stands at a staggering annual figure of Rs. 1400 crore
Figure 11: (a) Facial hypertrichosis (b) Striae alba
accounting for 82% among sale of all topical dermatological

Table 3: Components of vehicles of topical steroids

that cause side effect
Side effect Causative components of vehicle
Stinging Lactic acid, urea, formaldehyde, benzoic acid,
sorbic acid, cinnamic acid compound
Irritation Propylene glycol, alcohol, acetone
Contact Formaldehyde, benzoic acid, sorbic acid, cinnamic
urticaria acid compound, acetic acid, balsm of Peru, alcohol
Allergic contact Propyl gallate, sorbic acid, parabens,
dermatitis formaldehyde

Table 4: General measures to prevent topical steroid

induced side effects
General measures to topical steroid induced side effects
To achieve disease control use by potent steroids
To continue with a less potent steroid after sufficient response
Figure 12: Striae secondary to steroid application for tinea corporis
To reduce frequency of application e.g., alternate-day therapy or
weekend use
To continue daily application with the weakest effective steroid
To taper treatment on complete healing
To take care in treating children and elderly, especially at certain
locations like scrotum, face, flexures and periorbital area

Table 5: Measures to prevent side specific side effects

Side effect Preventive measure
Tachyphylaxis Use of lower-potency steroids
Application only in the morning
Alternate-day treatment
Avoidance of occlusion
Steroid-induced Use of topical tretinoin (without lessening
atrophy the steroid anti-inflammatory effect)
TS induced side Simultaneous use of topical keratolytics,
effect in psoriasis, such as salicylic acid for thickened plaques
chronic eczema Figure 13: Diffuse Hypopigmentation

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Coondoo, et al.: Side effects of topical steroids

a b
Figure 14: (a) Bilateral hypopigmentation (b) Facial patchy
hypopigmentation

Figure 15: Bilateral mild hypopigmentation with erythema and labial

hypertrichosis

a b
Figure 16: (a) Perilesional diffuse hypopigmentation Courtesy
Dr. Shyam Verma, (b) Perilesional diffuse hypopigmentation Courtesy
Dr. Shyam Verma

Figure 17: Diffuse scalp hypopigmentation

regarding TC manufacture and sales, particularly the rampant

OTC sale.[15] TC misuse benefits pharmaceutical industry but Figure 18: Atrophy and hypopigmentation secondary to IM steroids
the ultimate victims are the unaware populace. The onus of
countering this menace behoves on Indian dermatologists. Topical corticosteroid abuse on the face: A prospective, multicenter study of
A continuing chain of intensive awareness campaigns on their dermatology outpatients. Indian J Dermatol Venereol Leprol 2011;77:160-6.
part with relentless interaction with the policy makers may halt 3. Coondoo A, Chattopadhyay C. Use and abuse of topical corticosteroids
the relentless progress of TC abuse.[15] in children. Indian J Paediatr Dermatol 2014;15:1-4.
4. Berth-Jones J. Topical therapy. In: Burns T, Breathnach S, Cox N,
Griffiths C, editors. Rooks Textbook of Dermatology. 8th ed., Vol. 1.
REFERENCES UK: Blackwell Science Ltd.; 2010. p. 73.1-73.
5. Srinivas CR, Lakshmi C. Principles of topical therapy in dermatology. In:
1. Sulzberger MB, Witten VH. The effect of topically applied compound Valia RG, Valia AR, editors. IADVL Textbook of Dermatology. 3rd ed.,
F in selected dermatoses. J Invest Dermatol 1952;19:101-2. Vol. 2. Mumbai, India: Bhalani Publishing House; 2008. p. 1591-618.
2. Saraswat A, Lahiri K, Chatterjee M, Barua S, Coondoo A, Mittal A, et al. 6. Wolverton SE. Topical Corticosteroids. Comprehensive Dermatologic Drug

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Therapy. 2nd ed. Philadelphia USA: Saunders Elsevier; 2007. p. 595-624. 12. Verma SB, Hay R. Topical steroid induced tinea pseudoimbricata: A striking
7. Hsu SP. Formulary. In: Arndt KA, Hsu JT, editors. Manual of form of tinea incognito [Accepted for publication Int J Dermatol 2014].
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Source of Support: Nil, Conflict of Interest: None declared.
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