Topical glucocorticoids represent one of the most commonly prescribed and essential drugs for treating allergic skin disorders. They are available as combinations with antibiotics and antifungals. However, because of their immediate suppressive actions, fairness inducing effect, and low cost, their misuse, and abuse has increased, leading to several serious issues
1. Steroid Atrophy
Topical steroid use causes the skin to go through three phases-preatrophy, atrophy, and finally tachyphylaxis. Atrophy causes a burning sensation, and further steroid use causes vasoconstriction and soothing of the burning. When topical steroids are withdrawn, vasodilation occurs, till the vessels become more dilated than their initial diameter, and this is known as a "trampoline-like effect". This occurs due to the effect of steroids on nitric oxide in the endothelium. The release of endothelial nitric oxide stores results in "hyperdilation" of vessels.
2. Steroid Acne
The pathogenesis of topical steroid-induced acne has been proposed to be due to the degradation of the follicular epithelium, resulting in the extrusion of the follicular content. Factors predisposing to steroid acne are high concentration of the drug, application under occlusion, young adults below age 30, whites in preference to blacks and application to acne-prone areas of the face and upper back.
3. Perioral Dermatitis
Facial perioral dermatitis, more commonly seen in females, presents with follicular papules and pustules on an erythematous background, with sparing of the skin near the vermillion border of the lips. Steroid-induced perioral dermatitis is differentiated from common perioral dermatitis by history and clinical examination. Steroid-induced dermatitis has more erythema, inflammation, and scaling than its counterparts. Patients with steroid-induced dermatitis present with squeezed tubes of steroids that they have used and abused in hope of resolution of the skin condition.
4. Purpura, Stellate Pseudoscars, Ulcerations
Steroid-induced protein degradation leads to dermal atrophy and loss of intercellular substance, which further cause blood vessels to lose their surrounding dermal matrix, resulting in the fragility of dermal vessels, purpuric hypopigmented, and depressed scars.
5. Delayed wound healing
Delayed wound healing may occur due to various reasons. Inhibition of keratinocytes may cause epidermal atrophy and delayed re-epithelialization. Inhibition of fibroblasts-reduced collagen and ground substance may result in dermal atrophy and striae. Inhibition of vascular connective tissue may cause telangiectasia and purpura. Delayed granulation tissue formation may be caused by inhibition of angiogenesis.