Steroid-induced skin atrophy

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Steroid-induced skin atrophy
Skin atrophy
SpecialtyDermatology
Symptomstelangiectasias,[1] purpura, striae, hypopigmentation[2]
ComplicationsPossible HPA axis involvement[2]
Usual onsetwithin the first 7 days of daily superpotent TCS application under occlusion, within 2 weeks of daily use of less potent TCS or superpotent TCS without occlusion.[2]
CausesChanges in gene regulation and transcription of various mRNA[2]
Risk factorshigher potency corticosteroids, more frequent application, extended duration of treatment,[3] use of occlusion, infancy/childhood, location[2]
Diagnostic methodVisual inspection of skin for visible signs of skin atrophy[1]
PreventionIntermittent maintenance therapy; increasing duration of interval between applications[4]
ManagementDiscontinuation of treatment
PrognosisMost signs of atrophy resolve by 1 to 4 weeks after discontinuation of the TCS; striae are permanent[2]
Frequencyup to 5% after a year of use (in psoriasis)[5]

Steroid-induced skin atrophy is thinning of the skin as a result of prolonged exposure to topical steroids. This is the most common side effect of overuse or misuse of topical steroids.[6] Topical steroids are typically prescribed for psoriasis, atopic dermatitis (eczema), and other itchy rashes.[7] In people with psoriasis using topical steroids it occurs in up to 5% of people after a year of use.[5] Intermittent use of topical steroids for atopic dermatitis is safe and does not cause skin thinning.[8][9][10]

Skin atrophy can occur with both prescription and over the counter steroids creams.[11] Strength of the topical steroid will influence its propensity to cause skin atrophy.[12] Oral prednisone and intralesional steroids may also result in skin atrophy.[6][13]

Signs and symptoms

Steroid-induced atrophy

Skin atrophy typically presents as thin, shiny skin. Once it develops, further topical steroid side effects may occur, such as telangiectasia, easy bruising, purpura, and striae.[6][7][12] Application of topical steroids to intertriginous areas such as the armpits, under the breasts, or on the groin, use of occlusive dressings and fluorinated steroids all increase the likelihood of developing atrophy.[6][7][12][13][14]

Prevention

In general, use a potent preparation short term and weaker preparation for maintenance between flare-ups. While there is no proven best benefit-to-risk ratio,[15] if prolonged use of a topical steroid on a skin surface is required, a pulse therapy should be undertaken.

Pulse therapy refers to the application of a corticosteroid for 2 or 3 consecutive days each week or two. This is useful for maintaining control of chronic diseases. Generally a milder topical steroid or non-steroid treatment is used on the in-between days.[16]

For treating atopic dermatitis, newer (second generation) corticosteroids, such as fluticasone propionate and mometasone furoate, are more effective and safer than older ones. They are also generally safe and do not cause skin thinning when used in intermittently to treat atopic dermatitis flare-ups. They are also safe when used twice a week for preventing flares (also known as weekend treatment).[8][9][10] Applying once daily is enough as it is as effective as twice or more daily application.[17]

Strong steroids should be avoided on sensitive sites such as the face, groin and armpits.[7][12] Application of weak steroids to these areas should be limited to less than two weeks of continuous use.

Topical Steroid Classes

Topical steroids are divided into classes based on potency. Low potency steroids (hydrocortisone, triamcinolone acetonide) may be used on any surface of the body and for a longer period (typically 1-2 weeks).[12] Higher potency steroids (clobetasol, betamethasone) are reserved for severe pruritus that has been refractory to lower potency topical steroids.[7][12] Higher potency steroids are used for a shorter periods to control exacerbations.[7][12]

Treatment

The obvious priority is immediate discontinuation of any further topical corticosteroid use. Protection and support of the impaired skin barrier is another priority. Eliminating harsh skin regimens or products will be necessary to minimize potential for further purpura or trauma, skin sensitivity, and potential infection. Steroid-induced skin atrophy[18][19] is often permanent, though if caught soon enough and the topical corticosteroid discontinued in time, the degree of damage may be arrested or slightly improve. However, while the accompanying telangiectasias may improve marginally, the stretch marks are permanent and irreversible.[20]

See also

References

  1. ^ a b Vázquez-López F, Marghoob AA (November 2004). "Dermoscopic assessment of long-term topical therapies with potent steroids in chronic psoriasis". Journal of the American Academy of Dermatology. 51 (5): 811–813. doi:10.1016/j.jaad.2004.05.020. PMID 15523365.
  2. ^ a b c d e f Camisa C, Garofola C (2021). "Topical Corticosteroids". Comprehensive Dermatologic Drug Therapy. pp. 511–527.e6. doi:10.1016/B978-0-323-61211-1.00045-0. ISBN 978-0-323-61211-1.
  3. ^ Takeda K, Arase S, Takahashi S (1988). "Side effects of topical corticosteroids and their prevention". Drugs. 36 (Suppl 5): 15–23. doi:10.2165/00003495-198800365-00005. PMID 3076129. S2CID 23473646.
  4. ^ Lubach D, Rath J, Kietzmann M (1995). "Skin atrophy induced by initial continuous topical application of clobetasol followed by intermittent application". Dermatology. 190 (1): 51–55. doi:10.1159/000246635. PMID 7894098.
  5. ^ a b Castela E, Archier E, Devaux S, Gallini A, Aractingi S, Cribier B, et al. (May 2012). "Topical corticosteroids in plaque psoriasis: a systematic review of risk of adrenal axis suppression and skin atrophy". Journal of the European Academy of Dermatology and Venereology. 26 (Suppl 3): 47–51. doi:10.1111/j.1468-3083.2012.04523.x. PMID 22512680. S2CID 27244679.
  6. ^ a b c d Hengge UR, Ruzicka T, Schwartz RA, Cork MJ (January 2006). "Adverse effects of topical glucocorticosteroids". Journal of the American Academy of Dermatology. 54 (1): 1–15. doi:10.1016/j.jaad.2005.01.010. PMID 16384751.
  7. ^ a b c d e f Ference JD, Last AR (January 2009). "Choosing topical corticosteroids". American Family Physician. 79 (2): 135–140. PMID 19178066.
  8. ^ a b Harvey J, Lax SJ, Lowe A, Santer M, Lawton S, Langan SM, et al. (October 2023). "The long-term safety of topical corticosteroids in atopic dermatitis: A systematic review". Skin Health and Disease. 3 (5): e268. doi:10.1002/ski2.268. PMC 10549798. PMID 37799373.
  9. ^ a b Chu DK, Chu AW, Rayner DG, Guyatt GH, Yepes-Nuñez JJ, Gomez-Escobar L, et al. (December 2023). "Topical treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials". The Journal of Allergy and Clinical Immunology. 152 (6): 1493–1519. doi:10.1016/j.jaci.2023.08.030. hdl:10576/50632. PMID 37678572. S2CID 261610152.
  10. ^ a b Axon E, Chalmers JR, Santer M, Ridd MJ, Lawton S, Langan SM, et al. (July 2021). "Safety of topical corticosteroids in atopic eczema: an umbrella review". BMJ Open. 11 (7): e046476. doi:10.1136/bmjopen-2020-046476. PMC 8264889. PMID 34233978.
  11. ^ Abraham A, Roga G (September 2014). "Topical steroid-damaged skin". Indian Journal of Dermatology. 59 (5): 456–459. doi:10.4103/0019-5154.139872. PMC 4171912. PMID 25284849.
  12. ^ a b c d e f g Stacey SK, McEleney M (March 2021). "Topical Corticosteroids: Choice and Application". American Family Physician. 103 (6): 337–343. PMID 33719380.
  13. ^ a b Coondoo A, Phiske M, Verma S, Lahiri K (October 2014). "Side-effects of topical steroids: A long overdue revisit". Indian Dermatology Online Journal. 5 (4): 416–425. doi:10.4103/2229-5178.142483. PMC 4228634. PMID 25396122.
  14. ^ Weedon D (2010). "Disorders of collagen". Weedon's Skin Pathology. Elsevier. p. 303–329.e27. doi:10.1016/b978-0-7020-3485-5.00012-7. ISBN 978-0-7020-3485-5.
  15. ^ Ference JD, Last AR (January 2009). "Choosing topical corticosteroids". American Family Physician. 79 (2): 135–140. PMID 19178066.
  16. ^ "Course on topical steroids". 3 March 2024.
  17. ^ Lax SJ, Harvey J, Axon E, Howells L, Santer M, Ridd MJ, et al. (Cochrane Skin Group) (March 2022). "Strategies for using topical corticosteroids in children and adults with eczema". The Cochrane Database of Systematic Reviews. 2022 (3): CD013356. doi:10.1002/14651858.CD013356.pub2. PMC 8916090. PMID 35275399.
  18. ^ Fukaya M (2000). Color Atlas of Steroid Withdrawal from Corticosteroids in Patients with Atopic Dermatitis. Tokyo, Japan: Ishiyaku Publishers, Inc. Archived from the original on 2014-12-23. Retrieved 2014-12-23.
  19. ^ Fukaya M (June 2000). Atopic Dermatitis and Steroid Withdrawal (1st ed.). Japan: Ishiyaku Pub, Inc. p. 107. ISBN 978-4-263-20140-4. (skin atrophy caused during application of the steroid ointment).
  20. ^ "Steroid Atrophy".
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