Steroid-induced skin atrophy explained

Specialty:Dermatology
Symptoms:telangiectasias,[1] purpura, striae, hypopigmentation[2]
Complications:Possible HPA axis involvement
Onset:within 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.
Causes:Changes in gene regulation and transcription of various mRNA
Risks:higher potency corticosteroids, more frequent application, extended duration of treatment,[3] use of occlusion, infancy/childhood, location
Diagnosis:Visual inspection of skin for visible signs of skin atrophy
Prevention:Intermittent maintenance therapy; increasing duration of interval between applications[4]
Management:Discontinuation of treatment
Prognosis:Most signs of atrophy resolve by 1 to 4 weeks after discontinuation of the TCS; striae are permanent
Frequency:up to 5% after a year of use (in psoriasis)

Steroid-induced skin atrophy is thinning of the skin as a result of prolonged exposure to topical steroids. 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.[6] [7] [8]

Skin atrophy can occur with both prescription and over the counter steroids creams.[9] Low doses of prednisone by mouth can also result in skin atrophy.

Signs and symptoms

It can also present with telangiectasia, easy bruising, purpura, and striae. Occlusive dressings and fluorinated steroids both increase the likelihood of developing atrophy.[10]

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,[11] 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.[12]

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). Applying once daily is enough as it is as effective as twice or more daily application.[13]

Strong steroids should be avoided on sensitive sites such as the face, groin and armpits. Even the application of weaker or safer steroids should be limited to less than two weeks on those sites.

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[14] [15] 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.[16]

See also

Notes and References

  1. Vázquez-López . F . Marghoob . AA . Dermoscopic assessment of long-term topical therapies with potent steroids in chronic psoriasis. . Journal of the American Academy of Dermatology . November 2004 . 51 . 5 . 811–3 . 10.1016/j.jaad.2004.05.020 . 15523365.
  2. Camisa . Charles . Garofola . Craig . Topical Corticosteroids . Comprehensive Dermatologic Drug Therapy . 2021 . 511–527.e6 . 10.1016/B978-0-323-61211-1.00045-0. 9780323612111 .
  3. Takeda . K . Arase . S . Takahashi . S . Side effects of topical corticosteroids and their prevention. . Drugs . 1988 . 36 . Suppl 5 . 15–23 . 10.2165/00003495-198800365-00005 . 3076129. 23473646 .
  4. Lubach . D . Rath . J . Kietzmann . M . Skin atrophy induced by initial continuous topical application of clobetasol followed by intermittent application. . Dermatology . 1995 . 190 . 1 . 51–5 . 10.1159/000246635 . 7894098.
  5. Castela . E . Archier . E . Devaux . S . Gallini . A . Aractingi . S . Cribier . B . Jullien . D . Aubin . F . Bachelez . H . Joly . P . Le Maître . M . Misery . L . Richard . MA . Paul . C . Ortonne . JP . 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 . May 2012 . 26 . Suppl 3 . 47–51 . 10.1111/j.1468-3083.2012.04523.x . 22512680. 27244679 .
  6. Harvey J, Lax SJ, Lowe A, Santer M, Lawton S, Langan SM, Roberts A, Stuart B, Williams HC, Thomas KS . October 2023 . The long-term safety of topical corticosteroids in atopic dermatitis: A systematic review . Skin Health and Disease . 3 . 5 . e268 . 10.1002/ski2.268 . 10549798 . 37799373.
  7. Chu DK, Chu AW, Rayner DG, Guyatt GH, Yepes-Nuñez JJ, Gomez-Escobar L, Pérez-Herrera LC, Díaz Martinez JP, Brignardello-Petersen R, Sadeghirad B, Wong MM, Ceccacci R, Zhao IX, Basmaji J, MacDonald M, Chu X, Islam N, Gao Y, Izcovich A, Asiniwasis RN, Boguniewicz M, De Benedetto A, Capozza K, Chen L, Ellison K, Frazier WT, Greenhawt M, Huynh J, LeBovidge J, Lio PA, Martin SA, O'Brien M, Ong PY, Silverberg JI, Spergel JM, Smith Begolka W, Wang J, Wheeler KE, Gardner DD, Schneider L . 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 . 10.1016/j.jaci.2023.08.030 . 37678572 . 261610152.
  8. Axon E, Chalmers JR, Santer M, Ridd MJ, Lawton S, Langan SM, Grindlay DJ, Muller I, Roberts A, Ahmed A, Williams HC, Thomas KS . July 2021 . Safety of topical corticosteroids in atopic eczema: an umbrella review . BMJ Open . 11 . 7 . e046476 . 10.1136/bmjopen-2020-046476 . 8264889 . 34233978.
  9. Abraham . A . Roga . G . Topical steroid-damaged skin. . Indian Journal of Dermatology . September 2014 . 59 . 5 . 456–9 . 10.4103/0019-5154.139872 . 25284849. 4171912 . free .
  10. Book: Weedon, David . Weedon's Skin Pathology . Disorders of collagen . Elsevier . 2010 . 978-0-7020-3485-5 . 10.1016/b978-0-7020-3485-5.00012-7 . 303–329.e27.
  11. Choosing Topical Corticosteroids. American Family Physician. 79. 2. 135–140. 2009-01-15. Last. Allen R.. Ference. Jonathan D.. 19178066.
  12. Web site: Course on topical steroids.
  13. Lax SJ, Harvey J, Axon E, Howells L, Santer M, Ridd MJ, Lawton S, Langan S, Roberts A, Ahmed A, Muller I, Ming LC, Panda S, Chernyshov P, Carter B, Williams HC, Thomas KS, Chalmers JR . March 2022 . Strategies for using topical corticosteroids in children and adults with eczema . The Cochrane Database of Systematic Reviews . 2022 . 3 . CD013356 . 10.1002/14651858.CD013356.pub2 . 8916090 . 35275399 . Cochrane Skin Group.
  14. Book: Fukaya. Mototsugu. Color Atlas of Steroid Withdrawal from Corticosteroids in Patients with Atopic Dermatitis. 2000. Ishiyaku Publishers, Inc.. Tokyo, Japan. 2014-12-23. 2014-12-23. https://web.archive.org/web/20141223161030/http://www.tclinic.jp/atopy/eng/eng.html. dead.
  15. Book: Fukaya . Mototsugu . Atopic Dermatitis and Steroid Withdrawal . Ishiyaku Pub, Inc. . Japan . 978-4-263-20140-4 . 107 . 1st . June 2000 . (skin atrophy caused during application of the steroid ointment) .
  16. Web site: Steroid Atrophy.

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