Steroid-induced Skin Atrophy
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Steroid-induced skin atrophy is thinning of the skin at the level of the epidermis as a result of prolonged exposure to topical steroids. This is the most common side effect of overuse or misuse of topical steroids. Topical steroids are typically prescribed for psoriasis, atopic dermatitis (eczema), and other itchy rashes. In people with
psoriasis Psoriasis is a long-lasting, noncontagious autoimmune disease characterized by patches of abnormal skin. These areas are red, pink, or purple, dry, itchy, and scaly. Psoriasis varies in severity from small localized patches to complete b ...
using topical steroids it occurs in up to 5% of people after a year of use. Intermittent use of topical steroids for
atopic dermatitis Atopic dermatitis (AD), also known as atopic eczema, is a long-term type of inflammation of the skin. Atopic dermatitis is also often called simply eczema but the same term is also used to refer to dermatitis, the larger group of skin conditi ...
is safe and does not cause skin thinning. Skin atrophy can occur with both prescription and over the counter steroids. Potency of the topical steroid will influence its propensity to cause skin atrophy. Oral prednisone and intralesional steroids may also result in atrophied skin. Alternatives to topical steroids are available, depending on skin condition, with a reduced and different side effect profile.


Signs and symptoms

Skin atrophy typically presents as thin, shiny skin. Wrinkling of the skin and erythema may also be observed. In lighter skin tones, erythema presents as bright red, while darker skin tones appear more dark brown. Once atrophy develops, further and deeper topical steroid side effects may occur, such as
telangiectasia Telangiectasias (), also known as spider veins, are small dilated blood vessels that can occur near the surface of the skin or mucous membranes, measuring between 0.5 and 1 millimeter in diameter. These dilated blood vessels can develop anywhere ...
, easy bruising,
purpura Purpura () is a condition of red or purple discolored spots on the skin that do not blanch on applying pressure. The spots are caused by bleeding underneath the skin secondary to platelet disorders, vascular disorders, coagulation disorders, ...
, and
striae Stretch marks, also known as striae () or striae distensae, are a form of scarring on the skin with an off-color hue. Over time, they may diminish, but will not disappear completely. Striae are caused by tearing of the dermis during periods of ...
. Intralesional steroids may result in an indentation at the site of injection.


Diagnosis

Steroid-induced skin atrophy is a clinical diagnosis that is aided by patient history. A correlation between start of steroid application and presentation of side effects may be deduced. Key patient history features include amount of steroid applied, frequency and length of application, and location. An important distinction between a systemic versus external cause of skin conditions is symmetry and definition. Clues for an external cause include well-defined borders in the area of steroid application, as well as asymmetry. These physical findings support topical steroid etiology.


Treatment

The mainstay of steroid-induced skin atrophy treatment is immediate discontinuation of any further topical corticosteroid use. Protection and support of the impaired skin barrier is another priority. This can be achieved with utilizing gentle lotions, creams, and/or occlusives to restore the skin barrier. Eliminating harsh skin regimens or products will be necessary to minimize potential for further purpura or trauma, skin sensitivity, and potential infection.


Alternative treatment

Development of alternative treatment with less side effects are available. This secondary treatment may also be considered if treatment of the skin condition is refractory to topical steroids. Other treatment choices will depend on the skin condition being treated.


Atopic Dermatitis

Topical steroids are the primary treatment of choice for atopic dermatitis. However, topical immunomodulators (tacrolimus, pimecrolimus) and biologics are available options. The mechanism of these alternatives target a different pathway than topical steroids, which help reduce side effects.


Psoriasis

Topical treatment with steroids are effective in most cases of mild psoriasis. In cases refractory to topical steroids or in the presence of steroid side effects, topical vitamin D anologues (calcipotriol, calcipotriene) have shown to be effective. Off-label use of topical calcineurin inhibitors (tacrolimus, pimecrolimus) is also available with lesser known efficacy.


Prognosis

Steroid-induced skin atrophy 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. If cessation of topical steroid occurs while side effects are only at the level of the epidermis, these effects can be reversible. Deeper dermal damage is often irreversible. Dermal damage is typically marked by
telangiectasias Telangiectasias (), also known as spider veins, are small dilated blood vessels that can occur near the surface of the skin or mucous membranes, measuring between 0.5 and 1 millimeter in diameter. These dilated blood vessels can develop anywhere ...
and stretch marks. However, while the accompanying telangiectasias may improve marginally, the
stretch marks Stretch marks, also known as striae () or striae distensae, are a form of scarring on the skin with an off-color hue. Over time, they may diminish, but will not disappear completely. Striae are caused by tearing of the dermis during periods of ...
are permanent and irreversible.


Exacerbating factors

Common factors that increase the risk of skin thinning with steroid use include the following: # Applying too much steroid to the area of treatment # Using topical steroids for extended periods (>14–21 days) # Applying topical steroids to intertriginous areas such as the armpits, under the breasts, or on the groin # Using occlusive dressings, such as bandages, band aids, and clothing # Age (infancy/childhood, elderly)


Prevention


Finger-tip unit

Education on proper application and signs of steroid side effects are important in preventing permanent side effects. The fingertip unit (FTU) is a concept used to standardize amount of steroid applied per area of affected skin. One FTU is approximately 0.5 grams of medication that covers 2% of body surface area. It is defined as the amount of medication dispensed from the tip of the finger to the distal interphalangeal joint. Recommended FTU in a single application is determined by location of affected skin. The face and neck requires 2.5 fingertip units, the front trunk 7 fingertip units, the back trunk 7 fingertip units, one arm 3 fingertip units, one hand (front and back) 1 fingertip unit, one leg 6 fingertip units, and one foot 2 fingertip units.


Caution with high-potency steroid application

Strong steroids should be avoided on sensitive sites such as the face, inframammary folds, groin, and armpits. Application of weak steroids to these areas should be limited to less than two weeks of continuous use. In general, use a potent preparation short term and weaker preparation for maintenance between flare-ups.


Pulse therapy

While there is no proven best benefit-to-risk ratio, if prolonged use of a topical steroid is required, pulse therapy can be used as a mechanism to prevent side effects. 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.


Weekend treatment in atopic dermatitis

For treating
atopic dermatitis Atopic dermatitis (AD), also known as atopic eczema, is a long-term type of inflammation of the skin. Atopic dermatitis is also often called simply eczema but the same term is also used to refer to dermatitis, the larger group of skin conditi ...
, newer (second generation) corticosteroids, such as fluticasone propionate and
mometasone furoate Mometasone, also known as mometasone furoate, is a steroid (specifically, a glucocorticoid) medication used to treat certain skin conditions, hay fever, and asthma. Specifically it is used to prevent rather than treat asthma attacks. It can be ...
, are more effective and safer than older steroid generations. They are also generally safe and do not cause skin thinning when used 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.


Mechanism of action

Steroids have anti-inflammatory, anti-proliferative, and immunosuppressive effects that make it the mainstay of treatment for autoimmune and inflammatory conditions such as psoriasis and atopic dermatitis. Steroids bind intracellularly to their receptors found in the epidermis and dermis. Recent research has found transactivation of these receptors as a mechanism for steroid atrophy. Further research has shown the pathogenesis of skin atrophy is due to its inhibitory effects on key skin components at different levels of the skin. Keratinocyte proliferation is inhibited in the epidermis, while collagen 1 and 3 synthesis is halted at the dermis. Dermal atrophy intensifies with cessation of fibroblasts and hyaluronan synthase 3 enzyme leads because of decreased hyaluronic acid. Atrophic effects begin within 3–14 days of consistent topical steroid use and is first evident in the epidermal layer. Symptoms occurring at the level of epidermis are reversible. Prolonged use compromises the skin barrier integrity, which can cause dermal (more permanent) effects.


Topical Steroid Classes

The strength of topical steroids is an important consideration in choosing a steroid to prescribe. 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). Higher potency steroids (clobetasol, betamethasone) are reserved for severe pruritus that has been refractory to lower potency topical steroids. Higher potency steroids are used for a shorter periods to control exacerbations.


See also

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Topical steroid withdrawal Topical steroid withdrawal, also known as red burning skin and steroid dermatitis, has been reported in people who apply topical steroids for 2 weeks or longer and then discontinue use. Symptoms affect the skin and include redness, a burning sens ...
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Corticosteroid Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are invo ...
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Topical medication A topical medication is a medication that is applied to a particular place on or in the body. Most often topical medication means application to body surface area, body surfaces such as the skin or mucous membranes to treat ailments via a large ...


References

{{Reflist __NOTOC__ Drug safety Corticosteroids Cutaneous conditions