Topical Steroid Awareness and Abuse: A Prospective Study among Dermatology Outpatients

Background:Topical steroids are one of the most commonly abused drugs. There are only a few studies available which have highlighted the severity of this problem in India. However, these studies have concentrated mainly on the topical steroid abuse and its side effects over the face.Aims:The aim of this study was to know the awareness among the people about various commonly available topical steroids and their combinations irrespective of usage and to know the extent of misuse of these drugs. Along with this, we also tried to find the source of recommendation of these medicines which will help to sensitize people about this menace.Results:A total of 1000 adult patients were included in the study, out of which 809 (80.9%) patients had heard about at least one of the topical steroids or its combinations mentioned in the questionnaire. Six hundred and twelve (61.2%) patients had used these creams. Acne and pigmentation were the most common indications for which topical steroid was used. These medicines were recommended by general practitioners in 302 (49.5%) patients and pharmacists in 71 (11.6%) patients. Totally, 318 (51.9%) patients complained of some form of side effect after using these creams. Aggravation of the symptoms and increased pigmentation were the most common adverse effects.Conclusion:Misuse of topical steroids not just over the face but also as a cream for any skin problem is quite common. Most of the times, it is recommended by general practitioners or pharmacists. It is very important to sensitize these people about the possible complications of these drugs and the extent of problem the society is facing because of irrational and unregulated use of these drugs.     

Prevalence of Topical Steroid Misuse Among Rural Masses

Background:A lot of cosmetic and Ayurvedic products containing unlabeled depigmenting agent and steroids are available readily over the counter sale. The side effects of these products are not documented and can lead to adverse effects of continuous usage.Objective:By this study, we aimed to find out the true nature of the above problem and it''s implication in the Indian rural scenario.Methodology:All patients attending dermatology department during the period of 3 months from May to June 2013 for skin diseases were enquired about unsupervised use of any cosmetic product on their facial skin, duration of use, any side effect experienced through the prescribed questionnaire.Results:Total 50 patients were recruited for the study. Out of which, 48% were males and 52% were females. Seventy-four percent of people had applied topical products/steroids in an attempt of attainment of fair complexion, 14% for melasma, 8% for acne induced hyperpigmentation, and 4% for dark circles. About 80% people had obtained one or the other products over the counter sale, 8% had followed the attractive advertisements, 8% had started the application on the recommendation of friends/family while only 4% people had correctly gone through the proper channel to consult a dermatologist.Conclusion:The problem of topical products or steroids abuse is rampant and significant, and unless and until immediate steps are taken to root out this problem from our setup, the condition will become worse all the more.     

Systemic Side-Effects of Topical Corticosteroids

With the introduction of topical corticosteroids, a milestone has been achieved in dermatologic therapy; owing to its potent anti-inflammatory and ant proliferative effects, it became possible to treat some hitherto resistant dermatoses. But this magic drug can cause enough mischief if used inappropriately. Children are more susceptible to the systemic adverse effects because of enhanced percutaneous absorption through their tender skin. So, systemic side effects should be kept in mind while prescribing this therapeutically valuable topical medicament.     

Novel Medical Strategies Combating Nonmelanoma Skin Cancer

The incidence of nonmelanoma skin cancer (NMSC) continues to rise, partly because of aging, the frequency of early childhood sunburns, and sporadic extreme recreational sun exposure. A nonsurgical approach to selected cutaneous malignancy could possibly reduce the cost as well as morbidity of surgical treatment for NMSC. There has been growing interest in isolating compounds that could suppress or reverse the biochemical changes necessary for cutaneous malignancies to progress by pharmacologic intervention. By targeting diverse pathways recognized as important in the pathogenesis of nonmelanoma skin cancers, a combination approach with multiple agents or addition of chemopreventative agents to topical sunscreens may offer the potential for novel and synergistic therapies in treating nonmelanoma skin cancer. This preliminary information will expand to include more therapeutic options for NMSC in the future.     

Dermatological Side Effects of Epidermal Growth Factor Receptor Inhibitors: ‘PRIDE’ Complex

Epidermal growth factor receptor (EGFR) inhibitor therapy has become the standard treatment for non-small cell lung cancer and head neck malignancy. This class of drug comprises EGFR inhibitors (erlotinib and gefitinib) and monoclonal antibody (cetuximab). Use of this class of drugs has been associated frequently with dermatological side effects termed as PRIDE complex–Papulopustules and/or paronychia, Regulatory abnormalities of hair growth, Itching, Dryness due to EGFR inhibitors. We hereby report the cutaneous side effects of EGFR inhibitor therapy in 15 patients of lung and head/neck cancer. The major clinical findings being acneiform eruption and severe xerosis of skin. Management of these dermatological adverse effects rarely requires discontinuation of targeted therapy and can be managed symptomatically.     

METASTATIC CROHN'S DISEASE OF EXTERNAL GENITALIA

Metastatic Crohn''s disease is an uncommon extraintestinal manifestation of Crohn''s disease. Its hallmark features include the presence of cutaneous noncaseating granulomas that are noncontiguous with the gastrointestinal tract or fistula. We report a rare case of metastatic Crohn''s disease involving the external genitalia in a 14-year-old girl. Diagnosis was based on skin biopsy. Patient had complete recovery on treatment with oral and topical steroids along with azathioprine.     

COMPARATIVE ASSESSMENT OF TOPICAL STEROIDS, TOPICAL TRETENOIN (0.05%) AND DITHRANOL PASTE IN ALOPECIA AREATA

Background:

There have been various controversial reports regarding the efficacy of topical agents in topical therapy of alopecia areata.

Aim:

The study aims to find out the effective ones among the readily available ones for a dermatologist.

Materials and Methods:

Eighty patients were chosen from the skin OPD of Bankura Sammilani Medical College, Bankura, West Bengal, after evaluating the exclusion criterions. Treatments were continued for 3 month period and a follow up after further 3 months. After dividing them into four groups–group-I (topical steroids), group-II (topical tretinoin 0.05%) group-III (dithranol paste 0.25%), and group-IV (white soft petrolatum jelly)–patients were evaluated.

Results:

Seventy percent of group-I, 55% of group-II, 35% of group-III, and 20% of the control group (white soft petrolatum jelly) responded favorably. Side effects in the form of dermatitis and hyperpigmentation were seen in group-III. However, no patient discontinued from the study.

Conclusion:

We conclude that both topical steroids and tretinoin were fairly effective in limited variant of alopecia areata.     

Bilateral Multisegmental Zosteriform Leiomyoma Cutis: A Rare Entity

Cutaneous leiomyomas are benign tumors derived from the smooth muscles of the skin. They are firm, skin-colored to brownish, frequently painful papules and nodules presenting either as a solitary tumor or multiple clustered lesions. Uncommon patterns of multiple leiomyoma cutis include linear, zosteriform, or dermatomal-like arrangement of lesions. We saw a 32-year-old man who presented with clusters of skin colored to reddish brown, occasionally painful papules and nodules distributed segmentally over C6 to T8 dermatomes on left side and T11 to L1 dermatomes on right side. Histopathology confirmed the diagnosis of cutaneous leiomyoma. The case is reported here for the occurrence of this benign cutaneous neoplasm in an extremely rare bilateral multisegmental distribution.     

Study of reservoir effect of clobetasol propionate cream in an experimental animal model using histamine-induced wheal suppression test

Background:

Topical corticosteroids used in various dermatological diseases several times a day led to an increase risk of side effects. By demonstrating a significant reservoir of corticosteroids in the stratum corneum, one can maximize their efficacy and safety as therapeutic agents.

Aim:

The study was designed to demonstrate a reservoir of topically applied corticosteroid clobetasol propionate cream experimentally in rabbits using histamine-induced wheal suppression test.

Materials and Methods:

The work was carried out on albino rabbits, as rabbit skin is akin to human skin, using a topical steroid. The topical steroid clobetasol propionate 0.05% cream was applied on the back of rabbit, and after 1-h occlusion histamine-induced wheal suppression test was performed and wheal area measured at 10 min till day 7. Statistical analysis was done by ANOVA followed by “Post Hoc” test.

Results:

Maximum wheal suppression was seen on day 1 (P < 0.001). Interday comparison of mean wheal size showed no significant difference (P > 0.05) on day 2, 3, and 4 as compared to day 1. Day 5-7 show highly significant difference (P < 0.001) as compared to day 1, thereby suggesting that the reservoir effect of topical clobetasol propionate 0.05% cream persisted till day 4.

Conclusions:

This work demonstrated that histamine-induced wheal by the topical steroid clobetasol propionate 0.05% cream was suppressed till day 4, indicating that the reservoir of topical corticosteroid persisted till day 4.     

Exogenous Ochronosis

Exogenous ochronosis (EO) is a cutaneous disorder characterized by blue-black pigmentation resulting as a complication of long-term application of skin-lightening creams containing hydroquinone but may also occur due to topical contact with phenol or resorcinol in dark-skinned individuals. It can also occur following the use of systemic antimalarials such as quinine. EO is clinically and histologically similar to its endogenous counterpart viz., alkaptonuria, which, however, exhibits systemic effects and is an inherited disorder. Dermoscopy and in vivo skin reflectance confocal microscopy are noninvasive in vivo diagnostic tools. It is very difficult to treat EO, a cosmetically disfiguring and troubling disorder with disappointing treatment options.     

TOPICAL TREATMENT OF MELASMA

Melasma is a common hypermelanotic disorder affecting the face that is associated with considerable psychological impacts. The management of melasma is challenging and requires a long-term treatment plan. In addition to avoidance of aggravating factors like oral pills and ultraviolet exposure, topical therapy has remained the mainstay of treatment. Multiple options for topical treatment are available, of which hydroquinone (HQ) is the most commonly prescribed agent. Besides HQ, other topical agents for which varying degrees of evidence for clinical efficacy exist include azelaic acid, kojic acid, retinoids, topical steroids, glycolic acid, mequinol, and arbutin. Topical medications modify various stages of melanogenesis, the most common mode of action being inhibition of the enzyme, tyrosinase. Combination therapy is the preferred mode of treatment for the synergism and reduction of untoward effects. The most popular combination consists of HQ, a topical steroid, and retinoic acid. Prolonged HQ usage may lead to untoward effects like depigmentation and exogenous ochronosis. The search for safer alternatives has given rise to the development of many newer agents, several of them from natural sources. Well-designed controlled clinical trials are needed to clarify their role in the routine management of melasma.     

Epidermolysis bullosa acquisita with moderately severe Dysphagia due to esophageal strictures

Epidermolysis bullosa acquisita (EBA) is a chronic, autoimmune condition involving the skin and mucous membranes. Symptomatic mucosal involvement is rare, but can impact on quality of life, due to esophageal strictures and dysphagia. We report a case involving a 60-year-old male presenting with bullous skin lesions on areas of friction on his hands, feet and mouth. Milia were visible on some healed areas. Biopsy showed a subepidermal vesicle. Direct immunofluorescence showed intense linear junctional IgG and C3 at the dermo-epidermal junction. Serological tests also supported the diagnosis of EBA. Screening tests for underlying malignancies were negative. Despite treatment with systemic steroids, the patient developed increasing dysphagia, requiring further investigation with esophagoscopy and a barium swallow. Confirmation of extensive esophageal stricturing prompted adjustment of medications including an increase in systemic steroids and addition of azathioprine. Currently, the patient's disease remains under control, with improvement in all his symptoms and return of anti-basement membrane antibody levels to normal, whilst he remains on azathioprine 150 mg daily and prednisolone 5 mg daily. This case highlights the fact that the treatment of a given patient with EBA depends on severity of disease and co-morbid symptoms. Newer immunoglobulin and biological therapies have shown promise in treatment resistant disease. Considering that long-term immunosuppressants or biologicals will be required, potential side effects of the drugs should be considered. If further deterioration occurs in this patient, cyclosporin A or intravenous immunoglobulin (IV Ig) will be considered. Vigilance for associated co-morbidities, especially malignancies, should always be maintained.     

Dermatoses due to Quackery: A Case Snippet and Concise Review of Literature

A wide prevalence of socio-religious, cultural, and tribal practices in India often leads to a multitude of skin conditions, which can misled the dermatologists in arriving at a diagnosis. With increasing globalization and migration, the practice of indigenous customs and traditions are crossing boundaries, making it imperative for the dermatologists to be acquainted with the cutaneous side effects of these practices. Here, we report a unique case of thermal burn in a circumferential pattern over the umbilical region, a result of the placement of burning lamp over umbilicus to alleviate abdominal discomfort.     

Radiation Port Cutaneous Metastases: Reports of Two Patients Whose Recurrent Visceral Cancers Presented as Skin Lesions at the Site of Previous Radiation and Literature Review

Radiation therapy is associated with a variety of complications, including the development of primary skin cancers in the radiated region. However, it is rare for patients with visceral cancers who are treated with radiation therapy to subsequently develop cutaneous metastasis within the radiation port. We describe two patients with internal malignancies who developed cutaneous metastases within their radiation ports following radiotherapy. In addition, we used PubMed to perform an extensive literature review and identify additional reports of cutaneous metastasis within a radiation port. We excluded patients who developed melanoma or primary skin cancers in the radiation port. We also excluded patients with non-solid organ malignancies. Herein, we summarize the characteristics of 23 additional patients who experienced radiation port cutaneous metastases and explore possible mechanisms for the occurrence of radiation port cutaneous metastases.     

Topical Therapy in Atopic Dermatitis in Children

Atopic dermatitis (AD) is a common, chronic childhood skin disorder caused by complex genetic, immunological, and environmental interactions. It significantly impairs quality of life for both child and family. Treatment is complex and must be tailored to the individual taking into account personal, social, and emotional factors, as well as disease severity. This review covers the management of AD in children with topical treatments, focusing on: education and empowerment of patients and caregivers, avoidance of trigger factors, repair and maintenance of the skin barrier by correct use of emollients, control of inflammation with topical corticosteroids and calcineurin inhibitors, minimizing infection, and the use of bandages and body suits.     

Relevant Issues in Pharmacotherapy of Psycho-Cutaneous Disorders

Psychiatric disorders frequently co-occur with dermatological conditions and psychotropic agents may be indicated in treating the underlying psychiatric symptoms. Use of psychotropics can be associated with significant cutaneous adverse effects as well as drug interactions with pharmacological agents used in treatment of the dermatological conditions. Knowledge of indication, contraindication, side effects, and interactions of psycho-tropics is essential for the practicing dermatologist in managing psycho-dermatological conditions. This review aims at discussing relevant issues in pharmacological management of psycho-cutaneous disorders.     

Efficacy and safety of long-pulse pulsed dye laser delivered with compression versus cryotherapy for treatment of solar lentigines

Background:

Although cryotherapy is still the first-line therapy for solar lentigines, because of the side effects such as post-inflammatory hyperpigmentation (PIH), especially in patients with darker skin types, pigment-specific lasers should be considered as a therapy for initial treatment.

Aim:

The aim of this study is to evaluate the efficacy and safety of cryotherapy compared with 595-nm pulsed dye laser (PDL) with cutaneous compression in the treatment of solar lentigines.

Materials and Methods:

Twenty-two patients (skin type II–IV) with facial or hand lentigines participated in this study. Lesions of one side of the face or each hand were randomly assigned and treated with either cryotherapy or PDL. Treatments were performed with radiant exposures of 10 J/cm² , 7-mm spot size and 1.5 ms pulse duration with no epidermal cooling. Photographs were taken before treatment and 1-month later. The response rate and side effects were compared.

Results:

PDL was more likely to produce substantial lightening of the solar lentigines than cryotherapy, especially in skin type III and IV (n = 8, n = 9; P < 0.05), but might be no difference in type II (n = 5; P > 0.05). PIH was seen only in cryotherapy group. PDL group had only minimal erythema. No purpura was observed.

Conclusion:

PDL with compression is superior to cryotherapy in the treatment of solar lentigines in darker skin types.     

Steroid-induced rosacea: a clinical study of 200 patients

Background:

Topical corticosteroids were first introduced for use in 1951. Since then uncontrolled use (abuse) has caused many different reactions resembling rosacea – steroid dermatitis or iatrosacea. Multiple pathways including rebound vasodilatation and proinflammatory cytokine release have been proposed as the mechanism for such reactions.

Aim:

The aim was to study the adverse effects of topical steroid abuse and the response to various treatment modalities.

Materials and Methods:

Two hundred patients with a history of topical steroid use on face for more than 1 month were studied clinically and various treatments tried.

Results:

The duration of topical corticosteroid use varied from 1 month to 20 years with an average of 19.76 months. Majority of patients were using potent (class II) topical steroids for trivial facial dermatoses. The common adverse effects were erythema, telangiectasia, xerosis, hyperpigmentation, photosensitivity, and rebound phenomenon. No significant change in laboratory investigations was seen.

Conclusion:

A combination of oral antibiotics and topical tacrolimus is the treatment of choice for steroid-induced rosacea.