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Human steroidogenesis* Steroid Rosacea is recognized as a Rosacea Variant Steroids are sometimes used for rosacea and other skin conditions for treatment, usually in severe cases, for a limited time or short term therapy (scroll down to the subheading SHORT TERM STEROID TREATMENT). Steroids are not recommended for long term treatment of rosacea. If your doctor recommends a steroid treatment for your skin problem it should be explained to you what the benefits and risks or side effects associated with this treatment are. Usually the insert that comes from the product explains what these risks and side effects might be. Obviously, sometimes short term steroid treatment has been helpful to some who have had rosacea or other skin condition, or we wouldn't even hear of anyone being prescribed steroids. Topical Steroid Rosacea - image courtesy of Wikimedia Commons Steroid rosacea photos by DermNet NZ • Google images of Steroid Rosacea While some rosaceans have mixed the two, steroids and rosacea, it is not a good idea. And if you want some good advice, never mix the two. Do not use topical steroids on rosacea, period! Why is this such a problem that it is listed as a variant? Because rosaceans continue to use steroids or allow their physicians to treat them with steroids. An informed rosacean can decide whether the benefit of using steroids for rosacea is worth the risk, and your physician should explain the benefit/risk ratio to you. You have the choice to either accept the treatment or decline it. Dermatologists have been using topical corticosteroids since the 1950s treating intractable dermatoses. However, a report in 1988 says, "Disadvantages of corticosteroid activity include the possibility of adrenal suppression, epidermal and dermal thinning, and local effects such as purpura, striae, and steroid-induced rosacea and perioral dermatitis." [1] Various Names for Steroid Rosacea One paper calls it Facial corticosteroid addictive dermatitis (FCAD). [2] Another paper calls it Topical Steroid-Induced Facial Dermatosis [3] One paper designates this as Topical steroid dependent/damaged face (TSDF). [31] The names are a growing list. Another report called it "steroid dermatitis." [25] One paper calls it "Topical corticosteroid withdrawal ("steroid addiction")." [34] "Based on the patient’s history of the long-term topical corticosteroids and physical examination, we finally diagnosed this case as unilateral steroid-induced rosacea-like dermatitis (SIRD)." [36] "Topical steroid damaged face (TSDF) was a newly described phenomenon in 2008, which is characterized by a group of symptoms induced by the prolonged, unsupervised usage of TCs on the face, regardless of the potency." [37] History of Treating Skin Conditions with Steroids "...Corticosteroids were first introduced for topical use in dermatology in 1951. Since then uncontrolled use (abuse) has caused many different reactions, often with manifestations resembling those of rosacea..." [3] "...Dermocorticosteroids can be indicated in numerous inflammatory skin diseases (psoriasis, eczema ...). They are formally contraindicated in case of skin infections, diaper rash, acne and rosacea..." [4] "Never, never, never, ever prescribe steroids for rosacea." [5] Ironically, uninformed physicians sometimes prescribe steroids for rosacea or rosaceans may use over the counter non-prescription steroid topicals for rosacea and initially the rosacea may improve but after continuous use the rosacea gets worse. Hence the term, steroid-induced rosacea has developed due to uninformed rosaceans using long term topical steroids to treat rosacea or other skin conditions. This indicates that it is up to rosaceans to be informed and ask their physicians if they are keeping up with current treatment for rosacea. Reports still show that physicians prescribe steroids for acne rosacea, for example: "The first patient was treated with oral steroids, as well as doxycycline, to control his acne rosacea." (1998) [6] Here is a classic example of physicians treating rosacea with prednisolone, a steroid, in 1990: "Metronidazole was investigated in the basic dermatologic agent Elacutan W to improve the topical therapy of rosacea. The suitability of that basic dermatologic agent was verified for metronidazole, prednisolone and dexamethasone by stability tests (UV-spectroscopy, pH) and by in-vitro-liberation-measurements (membrane method). The drugs are stable for a period of 100 days." [7] And here is what these physicians should have read about prednisone in 1989: "A patient with malignant lymphoma repeatedly developed transient rosacea-like dermatitis several days after each interruption of continuous oral prednisone intake. We thought that the eruption was provoked by withdrawal of orally administered steroid, and thus we diagnosed the patient as having steroid-withdrawal rosacea-like dermatitis, one manifestation of steroid-withdrawal syndrome." [8] What is difficult to understand is that two variants of rosacea, Rosacea Fulminans, and Perioral Dermatitits are treated with Accutane and steroids. One report says that Corticosteroids and isotretinoin are regarded as the two main therapeutic agents for treating RF. [9] Periorol Dermatitis, a variant of rosacea, is sometimes the result of steroid use so rosaceans wonder what should they do if the physician prescribes steroids with all this conflicting data? Demodicosis may develop after the use of steroids according to the following two reports: "...the highest density of mites was found on the cheeks. A statistically significant increase in mites was found in all subgroups of rosacea, being most marked in those with steroid-induced rosacea...CONCLUSION: Increased mites may play a part in the pathogenesis of rosacea by provoking inflammatory or allergic reactions, by mechanical blockage of follicles, or by acting as vectors for microorganisms." [10] "...Demodex folliculorum were also more frequently detected in patients who had previously been treated with topical corticosteroids (even in 91.9%), what was often followed by epitheloid granulomas..." [11] However, one report in 2002 says the following: "...Recently, steroid components have been synthesized that aim to have adequate anti-inflammatory effects and minimal adverse effects. The newest topical corticosteroids used for the treatment of different dermatoses and allergic reactions of the respiratory tract (in particular asthma) are budesonide, mometasone furoate, prednicarbate, the di-esters 17,21-hydrocortisone aceponate and hydrocortisone-17-butyrate-21-propionate, methylprednisolone aceponate, alclometasone dipropionate, and carbothioates such as fluticasone propionate..." [12] As these new synthesized steroids are used, no doubt we will hear reports later of the long term effects for treating rosacea with these drugs. You as a rosacean have the right to ask questions about what treatment your doctor recommends. "...54% developed the steroid rosacea while being treated with the lowest-strength (class 7) topical corticosteroids. Even over-the-counter hydrocortisone preparations induced steroid rosacea in susceptible children. Susceptibility may be genetic as 20% of children had a first-degree relative with rosacea." [13] "...Initially, the mass was thought to be rhinophyma, but biopsy of the mass revealed noncaseating granulomata consistent with sarcoidosis. The mass resolved following several steroid injections..." [14] Apparently topical fluorinated steroid therapy resulted in an onset of smooth, shiny, erythematous papules on the face according to one report. [15] 1% hydrocortisone was applied to six patients. Three developed a rosacea-like eruption for the first time and one also had perioral dermatitis. [16] With Primary care physicians (PCPs), "When asked to rank the potency of 4 surveyed TCs [Topical Corticosteroids], 51.2% respondents were able to identify hydrocortisone acetate 1% cream as a low potent topical steroid." And with PCPs, "33.9% incorrectly responded that TCs can be used in all skin rashes, and 37.8% in acne vulgaris." [27] Tthe University of Bristol has found evidence that prolonged treatment of synthetic corticosteroid drugs increases adrenal gland inflammation in response to bacterial infection, an effect that in the long-term can damage adrenal function. [28] One report discusses the "Implications of Borderline Personality Disorder [with] Topical Steroid Dependence." [32] "Exposure to potent topical corticosteroids is associated with increased risk for osteoporosis and major fracture, according to an observational study in JAMA Dermatology." [33] "The long-term use of topical corticosteroids can result in rosacea-like dermatitis or facial perioral dermatitis." [35] Short Term Steroid Treatment for Rosacea Sometimes if your rosacea is severe your physician may prescribe short term steroid treatment, usually oral systemic steroid like Prednisone or in some cases a topical prescription steroid. Short term steroids are incredible to attenuate rosacea. [29] Treatment for Steroid Rosacea 0.03% tacrolimus and 595-nm pulsed dye laser [17] 1% pimecrolimus cream [18] FK506 (tacrolimus) may control the increase in IL-1alpha with glucocorticoid in KCs, suggesting FK506 to suppress harmful effects of glucocorticoids such as steroid rosacea. [19] Combination therapy of tetracyline and tacrolimus [20] However, one report of using Tacrolimus resulted in a "proliferation of Demodex due to local immunosuppression." [21] Caveat emptor! Another report concluded "Topical tacrolimus is becoming an important cause of RD [rosacea-like dermatitis] along with topical steroids." [24] A combination of oral antibiotics and topical tacrolimus is the treatment of choice for steroid-induced rosacea. [22] Treating Steroid Induced Rosacea, Linda Sy, MD [23] Calendula cream for steroid induced rosacea by May2012 Episofit A [26] Probiotics Topical 10% Tranexamic acid [31] Anecdotal Reports Henry Two Reports in one. M's report of what to do for steroid rosacea TrixP was diagnosed with dermatitis and treated with a steroid and developed steroid induced rosacea. reddy says, "My doctor gave me Daktakort cream which I have been using for the past 3 years but she told me if I kept using the cream it would make my skin very thin, only recently the cream has stopped working and when I use it now it makes my face even worse." Fallout2077 writes, "...however I stupidly continued to use this same steroid cream on and off for 3 years and then every single day for the next year. Whilst it did suppress the flakes and dryness, it made my face gradually become very sensitive, red and spotty and so i thought i had developed rosacea...." frank88 reports, "...I decided to cease the 1% cream on the 27th April about 20 days ago and my entire face has become very red, blotchy and inflammed with little pimples, all moreso in both the applications sites where I lightly applied the cream...." Reply to this Topic There is a reply to this topic button somewhere on the device you are reading this post. End Notes *Image courtesy of Wikimedia Commons [1] Clinical pharmacology and pharmacokinetic properties of topically applied corticosteroids. A review. Goa KL., Drugs. 1988;36 Suppl 5:51-61. [2] Facial corticosteroid addictive dermatitis in Guiyang City, China. Lu H, Xiao T, Lu B, Dong D, Yu D, Wei H, Chen HD. Clin Exp Dermatol. 2010 Aug;35(6):618-21. Epub 2009 Dec 8. [3] Steroid dermatitis resembling rosacea: aetiopathogenesis and treatment. Ljubojeviae S, Basta-Juzbasiae A, Lipozenèiae J. J Eur Acad Dermatol Venereol. 2002 Mar;16(2):121-6. [4] Local corticosteroid therapy in dermatology Chosidow O, Lebrun-Vignes B, Bourgault-Villada I. Presse Med. 1999 Nov 27;28(37):2050-6. [5] "Dr.Kligman (Dermatology-University of Philadelphia) & Dr. Plewig (Dermatologische Klinik Und Poliklinik der Universitat Munchen, Germany) state in their 1973 book, entitled Acne & Rosacea, First edition. Likewise, their second edition in 1993 harshly criticizes dermatologists that prescribe steroids for rosacea." Topical Steroids International Rosacea Foundation [6] Mooren's ulcer. Seino JY, Anderson SF. Optom Vis Sci. 1998 Nov;75(11):783-90. [7] Stability of metronidazole, prednisolone and dexamethasone in urea-containing Elacutan W dermatologic agent Heyde R, Dorsch S, Heidenreich S, Illig G. Dermatol Monatsschr. 1990;176(7):407-15. [8] Steroid-withdrawal rosacea-like dermatitis. Tomita Y, Tagami H. J Dermatol. 1989 Aug;16(4):335-7. [9] Rosacea fulminans in pregnancy. Lewis VJ, Holme SA, Wright A, Anstey AV. Br J Dermatol. 2004 Oct;151(4):917-9. [10] The Demodex mite population in rosacea. Bonnar E, Eustace P, Powell FC. J Am Acad Dermatol. 1993 Mar;28(3):443-8. [11] The possible role of skin surface lipid in rosacea with epitheloid granulomas. Basta-Juzbasić A, Marinović T, Dobrić I, Bolanca-Bumber S, Sencar J. Acta Med Croatica. 1992;46(2):119-23. [12] New and established topical corticosteroids in dermatology: clinical pharmacology and therapeutic use. Brazzini B, Pimpinelli N. Am J Clin Dermatol. 2002;3(1):47-58. [13] Steroid rosacea in prepubertal children. Weston WL, Morelli JG. Arch Pediatr Adolesc Med. 2000 Jan;154(1):62-4. [14] Sarcoidosis of the external nose mimicking rhinophyma. Case report and review of the literature. Goldenberg JD, Kotler HS, Shamsai R, Gruber B. Ann Otol Rhinol Laryngol. 1998 Jun;107(6):514-8. [15] Recent onset of smooth, shiny, erythematous papules on the face. Steroid rosacea secondary to topical fluorinated steroid therapy. Martin DL, Turner ML, Williams CM. Arch Dermatol. 1989 Jun;125(6):828, 831. [16] Complications of topical hydrocortisone. Guin JD., J Am Acad Dermatol. 1981 Apr;4(4):417-22. [17] Eur J Dermatol. 2016 Jun 1;26(3):312-4. doi: 10.1684/ejd.2016.2757. Recalcitrant steroid-induced rosacea successfully treated with 0.03% tacrolimus and 595-nm pulsed dye laser. Seok J, Choi SY, Li K, Kim BJ, Kim MN, Hong CK. [18] The use of 1% pimecrolimus cream for the treatment of steroid-induced rosacea. Chu CY., Br J Dermatol. 2005 Feb;152(2):396-9. [19] FK506 (tacrolimus) inhibition of intracellular production and enhancement of interleukin 1alpha through glucocorticoid application to chemically treated human keratinocytes. Horiuchi Y, Bae SJ, Katayama I., Skin Pharmacol Physiol. 2005 Sep-Oct;18(5):241-6. Rosacea: where are we now? Bikowski JB, Goldman MP. J Drugs Dermatol. 2004 May-Jun;3(3):251-61. [20] Combination therapy of tetracycline and tacrolimus resulting in rapid resolution of steroid-induced periocular rosacea. Pabby A, An KP, Laws RA., Cutis. 2003 Aug;72(2):141-2. [21] Induction of rosaceiform dermatitis during treatment of facial inflammatory dermatoses with tacrolimus ointment. Antille C, Saurat JH, Lübbe J. Arch Dermatol. 2004 Apr;140(4):457-60. [22] Steroid-induced rosacea: a clinical study of 200 patients. Bhat YJ, Manzoor S, Qayoom S. Indian J Dermatol. 2011 Jan;56(1):30-2. [23] Rosacea Support Treating Steroid Induced Rosacea December 4th, 2007, by David Pascoe [24] Tacrolimus-Induced Rosacea-Like Dermatitis: A Clinical Analysis of 16 Cases Associated with Tacrolimus Ointment Application. Teraki Y, Hitomi K, Sato Y, Izaki S. Dermatology. 2012 May 22. [25] ISRN Dermatol. 2013 Apr 21;2013:491376. doi: 10.1155/2013/491376. Print 2013. Steroid dermatitis resembling rosacea: a clinical evaluation of 75 patients. Hameed AF. [26] Georgian Med News. 2013 Oct;(223):31-5. Improvement of rosacea treatment based on the morphological and functional features of the skin. [Article in Russian] Tsiskarishvili NV, Katsitadze A, Tsiskarishvili Ts. Source: Tbilisi State Medical University, Department of Dermatology, Georgia. [27] Saudi Med J. 2017 Jun; 38(6): 662–665. doi: 10.15537/smj.2017.6.17586 PMCID: PMC5541192 Topical corticosteroids knowledge, attitudes, and practices of primary care physicians Sarah F. Alsukait, MBBS, Najd A. Alshamlan, MBBS, Zeina Z. Alhalees, MBBS, Sami N. Alsuwaidan, MD, and Abdulmajeed M. Alajlan, MD [28] Prolonged corticosteroid treatment increases adrenal gland inflammation, News Medical [29] Prednisone [30] Indian Dermatol Online J. 2020 Mar-Apr; 11(2): 208–211. Study of Clinical Profile of Patients Presenting with Topical Steroid-Induced Facial Dermatosis to a Tertiary Care Hospital Sonal Jain, Liza Mohapatra, Prasenjeet Mohanty, Swapna Jena, Binodini Behera [31] Indian Dermatol Online J. 2020 Nov-Dec; 11(6): 1024–1026. Topical 10% Tranexamic Acid for Recalcitrant Topical Steroid-Dependent Face Deepak Jakhar, Ishmeet Kaur, and Sachin Yadav [32] Indian J Psychol Med. 2020 Jul; 42(4): 396–398. Diagnostic and Therapeutic Implications of Borderline Personality Disorder on Topical Steroid Dependence: A Case Report Karthick Subramanian, Ashvini Vengadavaradan, Vigneshvar Chandrasekaran, Priyadarshini Manoharan, and Vikas Menon [33] NEJM, Journal Watch, MEDICAL NEWS | PHYSICIAN'S FIRST WATCH, January 21, 2021 Potent Topical Corticosteroids Tied to Increased Fracture Risk Amy Orciari Herman [34] J Dermatolog Treat. 2021 Jan 26;:1-24 Topical corticosteroid withdrawal ("steroid addiction"): An update of a systematic review. Hwang J, Lio PA Topical Steroid Addiction (TSA) and Topical Steroid Withdrawal (TSW) [35] Topical Steroid-Induced Perioral Dermatitis (TOP STRIPED): Case Report of a Man Who Developed Topical Steroid-Induced Rosacea-Like Dermatitis (TOP SIDE RED) [36] Yonago Acta Med. 2022 Feb; 65(1): 88–89. Infiltrative Erythemas and Nodules on a Unilateral Cheek Following Inappropriate Use of a Topical Steroid Ai Yoshida, Kazunari Sugita, Osamu Yamamoto [37] Clin Pract. 2022 Feb; 12(1): 140–146. Topical Steroid Damaged Face: A Cross-Sectional Study from Saudi Arabia Mahdi Al Dhafiri, Alaa Baqer Alali2 Zuhur Ali Alghanem, Zahraa Wasel Alsaleh, Eman Abdulrahman Boushel, Zahraa Baqer Alali, and Aeshah Adel Alnajjar Et Cetera Steroid-induced rosacea. Litt JZ. Case Western Reserve University School of Medicine, Cleveland, Ohio. Topical tacrolimus Protopic. Lazarous MC, Kerdel FA. Department of Dermatology and Cutaneous Medicine, University of Miami School of Medicine, Miami, FL 33136, USA. Potential future dermatological indications for tacrolimus ointment. Ruzicka T, Assmann T, Lebwohl M. Department of Dermatology, University of Dusseldorf, Moorenstr 5, 40225 Dusseldorf, Germsny Tacrolimus clinical studies for atopic dermatitis and other conditions. Bergman J, Rico MJ. Division of Pediatric and Adolescent Dermatology, Children's Hospital, San Diego, CA, USA. - 2001 Tacrolimus ointment for the treatment of steroid-induced rosacea: a preliminary report. Goldman D. - 2001 Rosacea in association with the progesterone-releasing intrauterine contraceptive device. Choudry K, Humphreys F, Menage J. Rosacea induced by beclomethasone dipropionate nasal spray. Egan CA, Rallis TM, Meadows KP, Krueger GG. Department of Dermatology, University of Utah School of Medicine, Salt Lake City 84132, USA. Practical aspects of local steroid treatment Gehring W, Gloor M. - 1989 Possible side effects of topical steroids. Morman MR. - 1981 Steroid rosacea in children. Franco HL, Weston WL. - 1979 Differential diagnosis of facial skin swellings (author's transl) Hornstein OP. - 1979 Perioral dermatitis (rosacea-like dermatitis)--adverse effects of externally applied steroid preparations Urabe H. - 1978 The treatment of steroid-induced rosacea and perioral dermatitis. Sneddon IB. - 1976 Perioral dermatitis and rosacea-like dermatitis: clinical features and treatment. Urabe H, Koda H. 1976 Steroid rosacea. Leyden JJ, Thew M, Kligman AM. Rosacea with steroid atrophy. Abell E, Borrie PF - 1969