What Are The Side Effects of Topical Steroids?
For several decades, topical steroids have served as a vital tool in the management of various dermatological conditions. These therapeutic agents display remarkable efficacy, often observable within a few days of initiation. However, despite their effectiveness, there exists a significant degree of concern regarding their potential adverse effects.
The specific adverse reaction ensuing from the use of topical steroids is influenced by a range of factors. These encompass the existence of underlying medical conditions, the site of application, the duration of treatment, individual genetic susceptibilities, and other patient-specific risk parameters.
Topical steroids find routine usage in treating dermatological ailments such as rashes or eczema. However, there is a subset of users who employ these medications exclusively for aesthetic enhancements. It is noteworthy that adverse reactions are more frequently reported in individuals with sensitive skin and when applied to certain body parts such as the face, groin, and hands for an extended period of time. It is important to understand that not all usage of topical steroids result in side-effects.
Outlined below are a few potential adverse effects associated with the use of topical steroids:
1. Tachyphylaxis
Tachyphylaxis is a rapid decrease in response to a topical steroid. In such instances, the dose of steroid used to keep psoriasis or eczema at bay suddenly becomes ineffective. Patients may be tempted to switch the steroid for a more potent one or use the same steroid for a more extended period. (1)
The tolerance range only increases if this happens and other adverse effects sprout.
2. Skin Atrophy
Overuse of topical steroids encourages skin thinning and atrophy. Vasoconstriction associated with steroid use causes a reduction in collagen levels, making the skin lose its plasticity. When the steroid is discontinued, a trampoline effect is witnessed. The blood vessels become far more dilated than they once were. This causes redness, blotching and sometimes the purple patches and spots associated with purpura and striae. (2)
Skin atrophy is associated with wrinkling and premature ageing of the skin.
Drying off skin is more prominent with facial skin and extremities (hands and legs). For this reason, potent steroids should not be used on the face, groin and other sensitive areas.
3. Stretch Marks
Topical steroids fight inflammation by inhibiting several pathways under the skin. Unfortunately, fighting swellings affect the blood supply to the dermis and epidermis. Prolonged use of steroids often decreases collagen, which shunts the firmness and plasticity of the skin. Thus when the skin is stretched, it does not retract as quickly as it naturally would.
When steroids are misused, stretch marks are more likely to form. (3) Depending on how long this misuse lasts, the stretch marks may be temporary, in which case the stretch lines disappear when the medication is discontinued, or at least four months after it was first sighted or permanent.
4. Steroid Rosacea
In the attempt to reduce inflammation on the face, a severe adverse reaction may occur. Steroid rosacea is an inflammatory condition experienced on withdrawal of a topical steroid.
It may resemble an allergic condition, but a closer examination reveals acne lesions like pustules, cysts and papules. (4) It may be triggered by a sudden cessation of steroid use, especially after using a medium or high potency steroid on the face.
To prevent such outbreaks, some doctors have advised to taper the dosage of a steroid slowly before completely discontinuing use.
Patients with outbursts of steroid rosacea admit to frequent use of a steroid before discontinuation. Unfortunately, this may be iatrogenic (caused by either the physician or the patient). In any case, close monitoring and slow withdrawal should be considered.
5. Glaucoma
The risk of glaucoma was formerly only attributed to the use of systemic steroids; however, recent evidence shows that due to the high absorption of topical steroids through the skin, applying a steroid to the skin around the eye may cause glaucoma. (5)
In glaucoma, the intraocular pressure is significantly increased by fluid retention. This may eventually damage the optic nerve and cause blindness.
Steroids play a part in the progression of glaucoma by encouraging water retention, locally and systemically. Thus, when applied close to the eye, it directs retained water to the organ.
Regular eye function tests are recommended for elderly patients who must use steroids.
6. Blindness
Topical steroids applied too close to the eye increase the risk of glaucoma and cataracts. In glaucoma, an increase in the volume of vitreous humour causes damage to the optical nerve, leading to blindness. (6) In cataracts, however, the reason for the clouding of the lens has not been identified. Gene transcription of epithelial cells is a probable mechanism, but more studies are necessary before a conclusion can be made.
The risk of blindness, although rare, remains with both topical and systemic steroid use.
7. Increased susceptibility to bacterial and fungal infections
Topical steroids identify inflammation as their primary enemy. Since inflammation is one of the most important defence mechanisms of the body, a topical steroid can render it difficult to defend itself from pathogens. (7)
When the inflammatory pathways remain suppressed for too long, the user is more likely to fall victim to bacterial and fungal infections. In cases where a topical steroid was used to treat a fungal skin disease, the condition only worsened and spread faster than a common fungal disease. This is because the steroid aided the infection by blocking the inflammatory pathways.
Before purchasing any over-the- counter steroid medication for a rash or other similar disease, it is essential to classify the condition as inflammatory, allergic, bacterial or fungal. This may better inform the choice of a topical treatment.
8. Ulceration on skin
The loss of blood supply seen in atrophy is also responsible for the formation of ulcers. Typically, after atrophy occurs, cells lose their intercellular substance, and the dermal matrix is broken. The dehydrated, parched skin is brittle and can be easily injured. When injuries occur, they can take twice as long to heal. Bacteria and fungi can easily infect these open sores, and these cause the wounds to spread, worsening with time. (8)
High cortisol levels in the blood aid this process by delaying wound healing. If they heal, they form a network of scars and dark purplish blotches.
9. Exacerbation of Herpetic Ulcers
The presence of immunosuppressive medication can be detrimental for when treating Herepes. A new herpes virus may penetrate the initial wound site in this short period of reduced inflammation, initiating a cascade of reactions. Keeping the immune system as active as possible prevents viral replication. (9)
10. Allergic Reactions
There is a possibility of allergy to topical steroids and the other ingredients used in the topical formulation. A patch test is vital in people with chronic skin conditions who are forced to use several steroids. (10)
With allergic reactions, immediate cessation of the topical steroid should diminish the symptoms.
11. Cushing’s syndrome
One of the primary ways steroids prevent inflammation is by releasing a class of hormones called Stress hormones. These hormones, cortisol and cortisone, are also present in the adrenal gland. Steroids stimulate the adrenal gland to back them up by producing an excess of these hormones. (11)
In Cushing’s syndrome, fluid retention causes oedema, obesity and high blood pressure. The signs and symptoms of Cushing’s syndrome include moon face, poor wound healing, stretch marks, ulcers, buffalo humps, amongst others. (12)
It may resemble diabetes by suppressing insulin sensitivity. It can worsen pre-existing obesity and hypertension by causing hyperlipidaemia and hyperglycemia.
12. Adrenal suppression
Topical steroids hijack the physiologic hypothalamic control of the adrenal glands. When there is an inflammatory condition, this may be a benefit. However, if a topical steroid is used for too long and the adrenal gland remains under control, it may lead to adrenal insufficiency when the steroid is finally ceased. (12)
In this case, neither the steroid nor the hypothalamus will stimulate the adrenal gland to produce corticosteroids.
Adrenal insufficiency can be a life-threatening condition(13)
13. Topical Steroid Addiction & Withdrawal
Topical Steroid Addiction can be described as the increased tolerance of the body to higher doses of topical corticosteroids and the onset of adverse effects upon cessation, causing serious withdrawal effects. These adverse effects are often much worse than the initial condition (such as eczema and acne) the steroids were being used to treat.
Signs and Symptoms of Topical Steroid Withdrawal
The most common symptom of topical steroid withdrawal (also known as Red Skin Syndrome) is a rebound of the underlying skin disease, followed by redness and an associated burning or stinging sensation. It can be difficult to determine if the rebound of the underlying skin disease means the patient requires different treatment to it is a case of topical steroid withdrawal.
There are certain things to look out for to determine if it is a case of topical steroid withdrawal:
- The patient experiences burning or stinging sensation rather than itching
- Rebound is worse than the original presentation of skin disease
- Symptoms extend further than the area of initial treatment and are different from the original presentation of skin disease
- Sites of visible inflammation (i.e. redness, darkening of the skin, or other change in color like pink or purple depending on the skin tone) are coalescent with the rest of the skin, not patchy.
- There has been a prolonged, frequent use of topical steroids.
Other symptoms of topical steroid withdrawal include:
- Skin flaking
- Edema
- Pus secretion from blisters caused by eczema (skin weeping/oozing)
- Skin peeling
- Hard bumps beneath the skin
- Pus filled bumps beneath the skin
- Skin alternates between redness, swelling, skin flaking, and secreting pus
- Lymph node enlargement
- Hair loss, both on the head and the body
- Fatigue
- Depression and Anxiety
- Insomnia
- Altered thermoregulation. The patient complains of feeling too cold or hot.
- Chills
- Skin hypersensitivity to water, fabric, movement, creams, temperature, etc.
- Red sleeves. There is redness of the arms and legs, excluding the palms and soles of the feet.
- Zaps of stabbing, squeezing, cold or prickly pain known as zingers
- Dryness and irritation of the eye
- Skin atrophy
- Changes in appetite
- Hot skin
- Hives
- Scabs
- Vision impairment, light sensitivity
Our Mission at TSW Assist
Our mission here at TSW Assist is to gather insights of medications, products, routines, supplements, and therapies that can help manage the symptoms experienced during withdrawal period from topical steroids. There is currently no cure for topical steroid withdrawal but these insights come directly from other people with TSW who have had success in symptomatic relief during their withdrawal period.
References
- du Vivier, A., & Stoughton, R. B. (1975). Tachyphylaxis to the action of topically applied corticosteroids. Archives of Dermatology, 111(5), 581-583.
- Lehmann, P., Zheng, P., Lavker, R. M., & Kligman, A. M. (1983). Corticosteroid atrophy in human skin. A study by light, scanning, and transmission electron microscopy. Journal of Investigative Dermatology, 81(2), 169-176.
- Ud‐Din, S., McGeorge, D., & Bayat, A. (2016). Topical management of striae distensae (stretch marks): prevention and therapy of striae rubrae and albae. Journal of the European academy of dermatology and venereology, 30(2), 211-222.
- Leyden, J. J., Thew, M., & Kligman, A. M. (1974). Steroid rosacea. Arch Dermatol, 110(4), 619-622.
- Razeghinejad, M. R., & Katz, L. J. (2012). Steroid-induced iatrogenic glaucoma. Ophthalmic research, 47(2), 66-80.
- Phulke, S., Kaushik, S., Kaur, S., & Pandav, S. S. (2017). Steroid-induced glaucoma: an avoidable irreversible blindness. Journal of current glaucoma practice, 11(2), 67.
- Pariser, D. M. (1991). Topical steroids: A guide for use in the elderly patient. Geriatrics, 46(10).
- Adams, B. B., & Sheth, P. B. (2002). Perianal ulcerations from topical steroid use. CUTIS-NEW YORK-, 69(1), 67-67.
- Thygeson, P., Hogan, M. J., & Kimura, S. J. (1960). The unfavorable effect of topical steroid therapy on herpetic keratitis. Transactions of the American Ophthalmological Society, 58, 245.
- Tatu, A. L., Ionescu, M. A., & Nwabudike, L. C. (2018). Contact allergy to topical mometasone furoate confirmed by rechallenge and patch test. American journal of therapeutics, 25(4), e497-e498.
- BORZYSKOWSKI, M., Grant, D. B., & Wells, R. S. (1976). Cushing’s syndrome induced by topical steroids used for the treatment of non‐bullous ichthyosiform erythroderma. Clinical and experimental dermatology, 1(4), 337-342.
- Güven, A., Gülümser, Ö., & Özgen, T. (2007). Cushing’s syndrome and adrenocortical insufficiency caused by topical steroids: misuse or abuse?. Journal of Pediatric Endocrinology and Metabolism, 20(11), 1173-1182.
- Böckle, B. C., Jara, D., Nindl, W., Aberer, W., & Sepp, N. T. (2014). Adrenal insufficiency as a result of long-term misuse of topical corticosteroids. Dermatology, 228(4), 289-293.
