ST. JULIANS, MALTA -- When you see clinical signs of rosacea, think "topical corticosteroid overuse." A large proportion of patients presenting with what looks to be rosacea actually have steroid-induced dermatitis, Dr. Suzana Ljubojevic said at the First World Congress of the International Academy of Cosmetic Dermatology. "They start using corticosteroids for seborrheic dermatitis or other dermatoses, and the steroids are often 'prescribed' by friends or relatives," said Dr. Ljubojevic of the department of dermatology, Zagreb Clinical Hospital, Croatia. At first, the anti-inflammatory and vasoconstrictive effects of the steroids result in what seems to be clearance of the primary dermatitis. But persistent use leads to epidermal atrophy, degeneration of dermal structure, and collagen deterioration after several months, she noted. In the end, the skin has the appearance of rosacea, and it is rendered extremely vulnerable to bacterial, viral, and fungal infection. Patients persist in using steroid creams or ointments because they have typically learned the hard way about the severe rebound inflammation that occurs if they stop. In short, they find themselves caught between rosacea like steroid dermatitis and the erythematous pustular eruptions of steroid rebound. By the time they present their condition to a dermatologist, they are very uncomfortable and unhappy. Dr. Ljubojevic and colleagues undertook a survey of 502 consecutive patients at their clinic with signs and symptoms of rosacea. There were 163 men and 339 women, spanning an age range of 15-79. Only 196 (39%) of the patients had never used corticosteroids. The remaining 306 (61%) were routine topical steroid users. They began to use corticosteroids for a wide range of primary diseases. The youngest patients were typically trying to get rid of acne. The oldest patient, a 79-year-old man, had begun steroids to treat keratosis. Dr. Ljubojevic noted that 331 of the 502 (66%) patients were positive for Demodex folliculorum. On initial assessment, it can be very difficult to distinguish between true rosacea and its steroid-induced mimic. The neck and scalp are often the giveaway, said Dr.Roger Allen of the University Hospital, Nottingham, England. Commenting on Dr. Ljubojevic's presentation, he pointed out that steroid-induced dermatitis is often diffuse, extending from the face down along the neck. In balding men, the scalp is often affected. True rosacea tends to be less diffuse. Dr Ljubojevic said there is no easy way to resolve steroid-induced dermatitis, short of ceasing steroid use. This is, admittedly, a hard sell to patients who have already experienced the severe erythema, edema, and pustular eruptions associated with steroid rebound. The severity of these symptoms can be minimized by avoiding use of cosmetics while the skin is vulnerable and by applying pH-neutral creams and lotions. Topical or systemic antibiotics may be needed if the patient has a bacterial infection. Dr. Ljubojevic and her colleagues have found cold chamomile tea compresses to be a soothing adjunct for patients in the throes of steroid backlash. It is important to explain the rebound phenomenon to these patients. They are often baffled by their observation that the same medicine that was so effective in clearing their primary dermatoses or acne is now causing this distressing rosacea like condition, and that their skin gets markedly worse if they stop treatment. Prudence in steroid use is essential, she stressed. "Patients with seborrheic dermatitis, acne vulgaris, or other dermatoses simply should not be treated with topical corticosteroids."
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