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Published: December 2005
ADR update

Topical Corticosteroids: Face Facts

Prescriber Update 26(2): 30-31
December 2005

Ruth Savage, Medical Assessor, CARM, New Zealand Pharmacovigilance Centre, Dunedin; and Marius Rademaker, Dermatologist, Hamilton

The use of topical corticosteroids on the face can result in harmful skin effects such as atrophy, telangiectasia and periorificial dermatitis.  These adverse reactions are greater with the more potent steroids but can be minimised by limiting use on the face.  The risks of facial use should be communicated to patients, along with clear directions about where to apply the topical steroid and for how long to continue treatment.

Topical steroids can cause unwanted skin effects

Whilst topical corticosteroids (creams, ointments and lotions) are helpful in the management of inflammatory skin disorders of the face, they can also cause a number of adverse skin effects.  These include thinning or atrophy of the skin (due to reduction in collagen), opportunistic infection, telangiectasia, purpura, periorificial dermatitis and the worsening of rosacea.1,2  Up to ten percent of women are prone to rosacea, which will be unmasked if they use steroids to treat other eczemas.3  Periorificial (previously known as perioral) dermatitis is most commonly induced by inappropriate use of steroids on the face.3,4  The risk of these adverse effects is greater with the more potent topical steroids, and is further increased when these preparations are applied under occlusion.2

Guide to potencies of topical corticosteroids available in New Zealand (brand names in brackets)2

Mildly Potent Moderately potent Potent Very potent
Hydrocortisone 0.5% and 1% Clobetasone butyrate 0.05% (Eumovate) Betamethasone dipropionate 0.05% (Diprosone) Clobetasol propionate 0.05% (Dermol)
  Triamcinolone acetonide 0.02% (Aristocort) Betamethasone valerate 0.1% (Beta, Betnovate)  
    Diflucortolone valerate 0.1% (Nerisone)  
    Hydrocortisone butyrate 0.1% (Locoid)  
    Methylprednisolone aceponate 0.1% (Advantan)  
    Mometasone furoate 0.1% (Elocon)  

New Zealand reports continue to be received

The Centre for Adverse Reactions Monitoring has received 14 reports, some recently, of facial skin damage attributed to the use of potent topical corticosteroids.  The adverse events included telangiectasia, abnormal pigmentation, periorificial dermatitis, rosacea, skin atrophy and striae.  These reports were primarily for mometasone but all topical steroids carry this risk, especially the more potent ones.

Minimise use on the face and inform patients of risks

While the reactions are well recognised, they are avoidable.  Prescribers are reminded that topical corticosteroids should not be used on the face except for very short periods (i.e. less than two weeks) for inflammatory dermatoses such as psoriasis and eczema that are unresponsive to other treatments.5  The use of topical corticosteroids on the eyelids or around the eyes should always be limited because the skin in this area is particularly thin.

Patients should be warned against using any steroid on their face unless advised to do so by their doctor, and that facial application should be limited to two weeks or less.  The risks of facial use should be clearly explained to patients.  The development or worsening of dermatitis around the mouth and eyes, or the development of erythema or prominent blood vessels on the cheeks, indicates that treatment should be discontinued.1,3

Provide patients with strict instructions for use

Prescriptions written for topical steroids should include explicit instructions about where and how often to apply the preparation, and the body areas where use must be avoided.  Pharmacists should ensure these directions are included on the dispensing label.  Prescribers should bear in mind that patients may keep unused or leftover corticosteroid skin preparations for some time after they are prescribed and thus forget the original indication or instructions for use.  The prescribing of unnecessarily large quantities should be avoided.  Patients should be warned not to share their topical steroid preparation with other people as this may result in unsafe application to unsuitable areas such as the face, as well as the potentially inappropriate treatment of undiagnosed skin conditions.

Competing interests (authors): none declared.

References
  1. Skin Disorders. In Davies DM, Ferner RE, de Glanville H (Eds) Davies's Textbook of Adverse Drug Reactions 5th Edn. 1998: London, p 577.
  2. Corticosteroids. In Sweetman SC (Ed) Martindale 34th Edn. 2005: Great Britain, p.1070-1075.
  3. Personal communication, 24 October 2005. Dermatologist, Hamilton. 
  4. DermNet NZ - web site of the New Zealand Dermatological Society Incorporated. Perioral dermatitis. http://dermnetnz.org/acne/perioral-dermatitis.html
  5. Rademaker M. Topical hydrocortisone. In Dollery CT (Ed) Therapeutic drugs. A clinical pharmacopoeia 2nd Edn. 1999: Edinburgh, p.H61-64.