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  Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 7  |  Issue : 4  |  Page : 259-263  

Misuse of topical corticosteroids on the face: A cross-sectional study among dermatology outpatients


Department of Dermatology, STD and Leprosy, All Institute of Medical Sciences, Patna, Bihar, India

Date of Web Publication5-Jul-2016

Correspondence Address:
Abhijeet Kumar Jha
Department of Dermatology, STD and Leprosy, All India Institute of Medical Sciences, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.185492

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   Abstract 

Background: Topical corticosteroids (TC) are being misused widely on the face without a prescription from the dermatologist. Aim: To evaluate the misuse of TC-containing preparations on the face and the adverse effects due to its application. Materials and Methods: A questionnaire-based analysis was done among patients attending the dermatology outpatient department of a tertiary care hospital between March 2014 and March 2015. Patients with various facial dermatoses were asked about their current use of topical preparations and on further followup questioning, those who revealed the use of TCs (25g or more) continuously or intermittently for a minimum duration of four weeks were included in the study and observed for local adverse effects. Results: A total of 410 patients were observed, 306 were females (74.6%) and 104 were males (25.3%). One hundred and seventy-eight patients (43.4%) used topical steroids alone, 124 (30.2%) used creams containing TC, hydroquinone, and tretinoin, 108 (26.3%) used creams containing a combination of TC, antibiotic, and/or antifungal. One hundred and seventy-six patients (42.9%) bought TC or TC containing creams over the counter on their own, without the prescription of a dermatologist, 35 (8.5%) were recommended TC by a beautician (beauty parlors), 82 (20%) by their friends, family members, or neighbors, 75 (18.2%) by a non-dermatologist practitioner, and 42 (10.2%) by a dermatologist. Limitations: The sample size was small. Conclusion: Dispensing of TCs must be regulated in India; they should only be issued against a doctor's prescription.

Keywords: Misuse, combination cream, topical steroids


How to cite this article:
Jha AK, Sinha R, Prasad S. Misuse of topical corticosteroids on the face: A cross-sectional study among dermatology outpatients. Indian Dermatol Online J 2016;7:259-63

How to cite this URL:
Jha AK, Sinha R, Prasad S. Misuse of topical corticosteroids on the face: A cross-sectional study among dermatology outpatients. Indian Dermatol Online J [serial online] 2016 [cited 2019 Aug 19];7:259-63. Available from: http://www.idoj.in/text.asp?2016/7/4/259/185492


   Introduction Top


TCs have been used for decades to treat various dermatological disorders due to their wide range of action. As TCs are freely available over the counter in India, they are prone for misuse without the dermatologist's prescription, increasing the risk of local and systemic side effects. Betamethasone valerate has been the favoured over the counter TC, the misconception being that it is a magical fairness and antiacne cream.


   Materials and Methods Top


A questionnaire-based analysis was done among patients attending dermatology outpatient department of a tertiary care hospital between March 2014 and March 2015. Prior approval of the Institutional Ethics Committee, and consent of patients was obtained.

Inclusion criteria

Patients using 25g or more of TC for 4 weeks or more were included in the study over the face.

Usage of a minimum of 25g (irrespective of the number of tubes used) of TC continuously for a minimum duration of two weeks was considered as continuous use.

Use of a minimum of 25g, (irrespective of the number of tubes used) of TC intermittently over the past four weeks was considered as intermittent use.

Use of TC without proper indication was considered as inappropriate use.

Exclusion criteria

Patients suffering from polycystic ovarian disease, Cushing's syndrome, chronic alcoholism, depression, or drug intake who may have features that resemble the side effects of TC.


   Results Top


Of the total 410 patients observed, 306 (74.6%) were females and 104 (25.3%) were males. One hundred and seventy-eight patients (43.4%) used topical steroids alone, 124 (30.2%) used creams containing TC, hydroquinone and tretinoin, 108 (26.3%) used creams containing a combination of TC, antibiotic, and/or antifungal. The various strengths of TCs used by patients is detailed in [Table 1].
Table 1: Use of various strengths of topical corticosteroids by patients

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One hundred and seventy-six patients (42.9%) bought TC or TC containing creams over the counter on their own, without the prescription of a dermatologist, 35 (8.5%) were recommended TC by a beautician (beauty parlors), 82 (20%) by their friends, family members, or neighbors, 75 (18.2%) by a non-dermatologist practitioner, and 42 (10.2%) by a dermatologist [Table 1],[Table 2],[Table 3].
Table 2: Localised adverse effects seen on the face due to misuse of topical corticosteroids

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Table 3: Total number of patients age group wise

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One hundred and thirty-eight patients (33.6%) in the age group of 20–29 years used TC [Table 3]. Out of 306 female patients, 119 (29%) were housewives, and 70 (17%) were school or college-going. The most common reason for patients' use of TC on the face was as a fairness cream in 146 patients (35.6%), melasma in 87 patients (21.2%), as antiacne cream in 84 patients (20.4%), as depigmenting agent in 42 patients (10.2%), redness reducing agent in 30 patients (8.2%), and for hypopigmentation in 11 patients (2.6%).

Localized adverse effects were noted [Table 2]. Steroid-induced acne [Figure 1] was seen in 176 patients (42.9%), followed by hypopigmentation [Figure 2] in 58 patients (14.1%), steroid dependency in 45 patients (10.9%), atrophy in 38 patients (9.2%), steroid induced erythema in 34 (8.2%) [Figure 3], perioral dermatitis in 21 patients (5.1%), [Figure 4], steroid induced rosacea [Figure 5] in 28 patients (6.8%) hirsuitism [Figure 6] in 12 patients (2.9%) and others, such as hyperpigmentation [Figure 7].
Figure 1: Steroid-induced acne

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Figure 2: Steroid-induced hypopigmentation

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Figure 3: Steroid-induced erythema

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Figure 4: Perioral dermatitis with hyperpigmentation

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Figure 5: Steroid induced rosacea

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Figure 6: Hirsuitism

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Figure 7: Steroid-induced hyperpigmentation

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   Discussion Top


TCs first came into existence more than 50 years ago, marking the most important milestone in dermatologic therapy owing to potent anti-inflammatory and antiproliferative effects.[1] Due to its varied mode of action, TC has been a cornerstone in the treatment of a few facial dermatoses. Since the TC are widely and easily available over the medicine counters, recommended by beauticians, friends, or neighbors. There has been a misconception about TC as fairness creams and antiacne agents. They are frequently used without a dermatological consultation. Even where dermatologists prescribe TC for an indicated facial dermatosis, there is risk of some patients using TC for prolonged periods, developing delayed local adverse effects. Similar studies have been reported from China [2],[3] and Iraq.[4] During the last few years a number of articles focusing on the issue have been published from India.[5],[6],[7],[8],[9],[10],[11],[12],[13],[14]

In a study from India by Saraswat et al., 433 patients were found to be using TC for facial dermatosis, 321 patients were female, which was similar to our study where out of 410 patients 306 were females 5. The reason behind this was probably more cosmetic concern and misconception that TC is a fairness or antiacne cream. In our study the most common adverse effect was acne. Of the 433 patients in the study group by Saraswat et al., 36% were of the age range of 21–30 years, similar to our study where 33.6% belonged to the age range of 20-29 years. The commonest adverse effect of TC in both studies was acne. However, only 42.9% developed TC-induced acne in our study as compared to 57.5% in a study by Saraswat et al. [Table 4] describes the comparison between the study conducted by Saraswat et al. versus our study. Out of 410 patients, TCs/combination cream were dispensed over the counter in 176 patients; betamethasone valerate alone were dispensed in 92 patients (22.4%) as fairness cream/antiacne cream, Kligman formula in 43 patients (10.4%) for melasma/other hyperpigmented lesion, and TC containing antifungal/antibiotic cream in 41 patients (10%) for tinea faciei/other facial dermatoses.
Table 4: Comparison between study by Saraswat et al.[5] and our study

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The adverse effects of TC are atrophy, telengiectasia, striae, hypopigmentation, hyperpigmentation, steroid rosacea, steroid acne, steroid induced folliculitis, tinea incognito, perioral dermatitis, tachyphylaxis, and hirsuitism. Topical steroids can rapidly induce an acneiform eruption.[15],[16],[17],[18] All topical steroids have been shown to cause skin atrophy, albeit to a variable degree.[19],[20] This phenomenon is reflected in increased transparency and shine of the skin, as well as the appearance of striae.[21],[22] Steroid-induced rosacea has been commonly associated with topical fluorinated corticosteroids.[9] There are approximately 700,000 chemists in India.[14] The latest National List of Essential Medicines (NLEM) of 348 drugs, updated in 2011, (revised 2014) has included only one topical steroid, betamethasone dipropionate [23] The team of experts invited by the Government of India to participate in preparing the NLEM of 2011 included only one dermatologist.[23]


   Conclusion Top


In our study, pharmacists or their staff had recommended use of topical steroids to 176 patients (42.9%), which raises serious concern. In India there should be a regulation of dispensing TCs and should only be given based on doctor's prescription. Strict regulation regarding only prescription-based dispensing of TCs must be put into practice.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Smith EW. Do we need new and different glucocorticoids? A re-appraisal of the various congeners and potential alternatives. Curr Probl Dermatol 1993;21:1-10.  Back to cited text no. 1
    
2.
Lu H, Xiao T, Lu B, Dong D, Yu D, Wei H, et al. Facial corticosteroid addictive dermatitis in Guiyang city, China. Clin Exp Dermatol 2010;35:618-21.  Back to cited text no. 2
    
3.
Liu ZH, Du XH. Quality of life in patients with facial steroid dermatitis before and after treatment. J Eur Acad Dermatol Venereol 2008;22:663-9.  Back to cited text no. 3
    
4.
Al-Dhalimi MA, Aljawahiry N. Misuse of topical corticosteroids: A clinical study in an Iraqi hospital. East Mediterr Health J 2006;12:847-52.  Back to cited text no. 4
    
5.
Saraswat A, Lahiri K, Chatterjee M, Barua S, Coondoo A, Mittal A, et al. Topical corticosteroid abuse on the face: A prospective, multicenter study of dermatology outpatients. Indian J Dermatol Venereol Leprol 2011;77:160-6.  Back to cited text no. 5
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Rathi SK, D'Souza P. Rational and ethical use of topical corticosteroids based on safety and efficacy. Indian J Dermatol 2012;57:251-9.  Back to cited text no. 6
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Saraswat A. Topical corticosteroid use in children: Adverse effects and how to minimize them. Indian J Dermatol Venereol Leprol 2010;76:225-8.  Back to cited text no. 7
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Kumar MA, Noushad PP, Shailaja K, Jayasutha J, Ramasamy C. A study on drug prescribing pattern and use of corticosteroids in dermatological conditions at a tertiary care teaching hospital. Int J Pharm Sci Rev Res 2011;9:132-5.  Back to cited text no. 8
    
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Bhat YJ, Manzoor S, Qayoom S. Steroid-induced rosacea: A clinical study of 200 patients. Indian J Dermatol 2011;56:30-2.  Back to cited text no. 9
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Rathi SK, Kumrah L. Topical corticosteroid-induced rosacea-like dermatitis: A clinical study of 110 cases. Indian J Dermatol Venereol Leprol 2011;77:42-6.  Back to cited text no. 10
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Saraswat A. Contact allergy to topical corticosteroids and sunscreens. Indian J Dermatol Venereol Leprol 2012;78:552-9.  Back to cited text no. 11
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Rathod SS, Motghare VM, Deshmukh VS, Deshpande RP, Bhamare CG, Patil JR. Prescribing practices of topical corticosteroids in the outpatient dermatology department of a rural tertiary care teaching hospital. Indian J Dermatol 2013;58:342-5.  Back to cited text no. 12
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Coondoo A, Chattopadhyay C. Use and abuse of topical corticosteroids in children. Indian J Paediatr Dermatol 2014;15:1-4.  Back to cited text no. 13
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Verma SB. Sales, status, prescriptions and regulatory problems with topical steroids in India. Indian J Dermatol Venereol Leprol 2014;80:201-3.  Back to cited text no. 14
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Plewig G, Kligman AM. Induction of acne by topical steroids. Arch Dermatol Forsch 1973;247:29-52.  Back to cited text no. 15
    
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Fulton JE, Kligman AM. Aggravation of acne vulgaris by topical application of corticosteroids under occlusion. Cutis 1968;4:1106.  Back to cited text no. 16
    
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Kaidbey KH, Kligman AM. The pathogenesis of topical steroid acne. J Invest Dermatol 1974;62:31-6.  Back to cited text no. 17
    
18.
Litt JZ. Steroid-induced rosacea. Am Fam Physician 1993;48:67-71.  Back to cited text no. 18
    
19.
Kirby JD, Munro DD. Steroid-induced atrophy in an animal and human model. Br J Dermatol 1976;94 Suppl 12:111-9.  Back to cited text no. 19
    
20.
Kligman LH, Schwartz E, Lesnik RH, Mezick JA. Topical tretinoin prevents corticosteroid-induced atrophy without lessening the anti-inflammatory effect. Curr Probl Dermatol 1993;21:79-88.  Back to cited text no. 20
    
21.
Wester RC, Maibach HI. Dermatophamacokinetics in clinical dermatology. Semin Dermatol 1983;2:81-4.  Back to cited text no. 21
    
22.
Epstein NM, Epstein WL, Epstein JH. Atrophic striae in patients with inguinal intertrigo. Arch Dermatol 1963;87:450.  Back to cited text no. 22
    
23.
World Health Organization. National List of Essential Medicines of India. Available from: . [Last accessed on 2014 Jan 18].  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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