Steroid rosacea

Steroid rosacea
Specialty	Dermatology

Last updated February 25, 2019

Steroid-induced rosacea is an iatrogenic condition (induced by the physician or patient) from the use of either systemic steroid or topical steroids. It is nearly identical to steroid induced acne from the standpoint of etiology.^[1]

Iatrogenesis refers to any effect on a person, resulting from any activity of one or more other persons acting as healthcare professionals or promoting products or services as beneficial to health, which does not support a goal of the person affected.

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 involved in a wide range of physiological processes, including stress response, immune response, and regulation of inflammation, carbohydrate metabolism, protein catabolism, blood electrolyte levels, and behavior.

Acne, also known as acne vulgaris, is a long-term skin disease that occurs when hair follicles are clogged with dead skin cells and oil from the skin. It is characterized by blackheads or whiteheads, pimples, oily skin, and possible scarring. It primarily affects areas of the skin with a relatively high number of oil glands, including the face, upper part of the chest, and back. The resulting appearance can lead to anxiety, reduced self-esteem and, in extreme cases, depression or thoughts of suicide.

Cause

Steroid-induced rosacea can be caused by the prolonged used of a topical steroid on the face. Topical steroid comes in 7 different strengths (Some countries use 4 categories). Class I is super potent, and class VII is very weak. Usually, any categories of steroids over class VI can induce rosacea with prolonged use. The typical presentation is inflammatory acne lesions consisting of pustules, papules, and cysts. The patient often admits to the daily use of a topical steroid, often being under the advisement of a physician. Examination of the pustules often revealed inflammatory cells, and in many cases, numerous motile demodex mites.

A papule is a circumscribed, solid elevation of skin with no visible fluid, varying in area from a pinhead to 1 cm. It can be brown, purple, pink or red in color, and can cluster into a papular rash. Papules may open when scratched and become infected and crusty. Larger non-blisterform elevated lesions may be termed nodules.

A cyst is a closed sac, having a distinct membrane and division compared with the nearby tissue. Hence, it is a cluster of cells that has grouped together to form a sac ; however, the distinguishing aspect of a cyst is that the cells forming the "shell" of such a sac are distinctly abnormal when compared with all surrounding cells for that given location. It may contain air, fluids, or semi-solid material. A collection of pus is called an abscess, not a cyst. Once formed, sometimes a cyst may resolve on its own. When a cyst fails to resolve, it may need to be removed surgically, but that would depend upon its type and location.

A physician, medical practitioner, medical doctor, or simply doctor is a professional who practises medicine, which is concerned with promoting, maintaining, or restoring health through the study, diagnosis, prognosis and treatment of disease, injury, and other physical and mental impairments. Physicians may focus their practice on certain disease categories, types of patients and methods of treatment—known as specialities—or they may assume responsibility for the provision of continuing and comprehensive medical care to individuals, families, and communities—known as general practice. Medical practice properly requires both a detailed knowledge of the academic disciplines underlying diseases and their treatment—the science of medicine—and also a decent competence in its applied practice—the art or craft of medicine.

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Last updated February 25, 2019

Prevention

Physicians need to be aware of the danger of topical steroids. Only mild steroids should be applied to the face. The use of the topical steroid should be limited to the condition. Alternate week therapy or 3 consecutive days a week therapy is better than continuous therapy in preventing steroid-induced rosacea. Only the mildest topical steroid should be used on the face if a condition warrants such use. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) does not necessary prevent steroid induced rosacea. Similar conditions have been seen with both Elidel and Protopic, possibly from immunosuppression and Demodex or bacterial growth.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a drug class that reduce pain, decrease fever, prevent blood clots and, in higher doses, decrease inflammation. Side effects depend on the specific drug, but largely include an increased risk of gastrointestinal ulcers and bleeds, heart attack and kidney disease.

Immunosuppression decreased resistance to infection; reduction of the activation or efficacy of the immune system

Immunosuppression is a reduction of the activation or efficacy of the immune system. Some portions of the immune system itself have immunosuppressive effects on other parts of the immune system, and immunosuppression may occur as an adverse reaction to treatment of other conditions.

Demodex is a genus of tiny mites that live in or near hair follicles of mammals.

Treatment

Treatment often involves the gradual weaning off the topical steroid, and the use of a systemic anti-inflammatory antibiotic. If the patient is using a strong topical steroid, he or she is weaned to a weaker class VI or VII steroid. Usually, they are to use the substitute steroid daily, then only on weekends, then stop completely. The facial dermatitis and discomfort often worsen when they stop the offending steroid. The oral antibiotic will decrease the inflammatory nature of the lesions. The antibiotic of choice is usually a tetracycline antibiotic. Additionally, tacrolimus combined with oral antibiotics has proven to speed up the recovery process.^[2]^[3]

Dermatitis, also known as eczema, is a group of diseases that results in inflammation of the skin. These diseases are characterized by itchiness, red skin and a rash. In cases of short duration, there may be small blisters, while in long-term cases the skin may become thickened. The area of skin involved can vary from small to the entire body.

Tacrolimus, also known as fujimycin or FK506, is an immunosuppressive drug used mainly after allogeneic organ transplant to lower the risk of organ rejection. It achieves this by inhibiting the production of interleukin-2, a molecule that promotes the development and proliferation of T cells, which are vital to the body's learned immune response. Tacrolimus is also used in the treatment of other T cell-mediated diseases such as eczema, severe refractory uveitis after bone marrow transplants, exacerbations of minimal change disease, Kimura's disease, and the skin condition vitiligo.

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Minocycline is a broad-spectrum tetracycline antibiotic, and has a broader spectrum than the other members of the group. It is a bacteriostatic antibiotic, classified as a long-acting type. As a result of its long half-life, it generally has serum levels two to four times that of the simple water-soluble tetracyclines.

Folliculitis is the infection and inflammation of one or more hair follicles. The condition may occur anywhere on the skin except the palms of the hands and soles of the feet. The rash may appear as pimples that come to white tips on the face, chest, back, arms, legs, buttocks, or head.

Demodicosis, also called demodectic mange or red mange, is caused by a sensitivity to and overpopulation of Demodex canis as the host's immune system is unable to keep the mites under control.

Blepharitis is one of the most common ocular conditions characterized by inflammation, scaling, reddening, and crusting of the eyelid. This condition may also cause burning, itching, or a grainy sensation when introducing foreign objects or substances to the eye. Although blepharitis is not sight-threatening, it can lead to permanent alterations of the eyelid margin. The overall etiology is a result of bacteria and inflammation from congested meibomian oil glands at the base of each eyelash. Other conditions may give rise to blepharitis, whether they be infectious or noninfectious, including, but not limited to, bacterial infections or allergies.

Rosacea long-term human skin disease characterized by ruddy reddening of the skin

Rosacea is a long-term skin condition that typically affects the face. It results in redness, pimples, swelling, and small and superficial dilated blood vessels. Often the nose, cheeks, forehead, and chin are most involved. A red enlarged nose may occur in severe disease, a condition known as rhinophyma.

Miliaria, also called "sweat rash", is a skin disease marked by small and itchy rashes due to sweat trapped under the skin by clogged sweat gland ducts. Miliaria is a common ailment in hot and humid conditions, such as in the tropics and during the summer season. Although it affects people of all ages, it is especially common in children and infants due to their underdeveloped sweat glands.

Perioral dermatitis is a type of skin rash. Symptoms include multiple small (1–2 mm) bumps and blisters sometimes with background redness and scale, localized to the skin around the mouth and nostrils. Less commonly the eyes and genitalia may be involved. It can be persistent or recurring and resembles particularly rosacea and to some extent acne and allergic dermatitis. The term dermatitis is a misnomer because this is not an eczematous process.

Prurigo nodularis (PN), also known as nodular prurigo, is a skin disease characterised by pruritic (itchy) nodules which usually appear on the arms or legs. Patients often present with multiple excoriated lesions caused by scratching. PN is also known as Hyde prurigo nodularis, Picker's nodules, atypical nodular form of neurodermatitis circumscripta, lichen corneus obtusus.

Management of ulcerative colitis involves first treating the acute symptoms of the disease, then maintaining remission. Ulcerative colitis is a form of colitis, a disease of the intestine, specifically the large intestine or colon, that includes characteristic ulcers, or open sores, in the colon. The main symptom of active disease is usually diarrhea mixed with blood, of gradual onset which often leads to anaemia. Ulcerative colitis is, however, a systemic disease that affects many parts of the body outside the intestine.

Acne fulminans is a severe form of the skin disease, acne, which can occur after unsuccessful treatment for another form of acne, acne conglobata. The condition is thought to be an immunologically induced disease in which elevated level of testosterone causes a rise in sebum and population of Propionibacterium acnes bacteria. The increase in the amount of P acnes or related antigens may trigger the immunologic reaction in some individuals and lead to an occurrence of acne fulminans. In addition to testosterone, isotretinoin may also precipitate acne fulminans, possibly related to highly increased levels of P acnes antigens in the patient's immune system. Acne fulminans is a rare disease. Over the past several years, fewer cases of this disease have occurred, possibly because of earlier and better treatment of acne. Approximately 100 patients with acne fulminans have been described.

Acne medicamentosa is acne that is caused or aggravated by medication. Because acne is generally a disorder of the pilosebaceous units caused by hormones, the medications that trigger acne medicamentosa most frequently are hormone analogs. It is also often caused by corticosteroids; in this case, it is referred to as steroid acne.

The term skin flora refers to the microorganisms which reside on the skin, typically human skin.

Nadifloxacin is a topical fluoroquinolone antibiotic for the treatment of acne vulgaris. It is also used to treat bacterial skin infections.

Actinic prurigo is a rare sunlight-induced, pruritic, papular or nodular skin eruption. Some medical experts use the term actinic prurigo to denote a rare photodermatosis that develops in childhood and is chronic and persistent; this rare photodermatosis, associated with the human leukocyte antigen HLA-DR4, is often called "Familial polymorphous light eruption of American Indians" or "Hereditary polymorphous light eruption of American Indians" but some experts consider it to be a variant of the syndrome known as polymorphous light eruption (PMLE). Some experts use the term actinic prurigo for Hutchinson's summer prurigo and several other photodermatoses that might, or might not, be distinct clinical entities.

Acne conglobata is a highly inflammatory disease presenting with comedones, nodules, abscesses, and draining sinus tracts.

Persistent edema of rosacea is a hard, nonpitting edema found on the areas involved, those mainly being the forehead, glabella, upper eyelids, nose, and/or cheeks.

Gnathophyma involves swelling of the chin. It is a type of lesion associated with rosacea, a common chronic inflammatory skin disorder of the sebaceous glands characterized by redness, swelling, and acne-like pustules.

Pimple blister containing purulent fluid

A pimple is a kind of comedo resulting from excess sebum and dead skin cells getting trapped in the pores of the skin. In its aggravated state, it may evolve into a pustule or papules. Pimples can be treated by acne medications, antibiotics, and anti-inflammatories prescribed by a physician, or various over the counter remedies purchased at a pharmacy.

Majocchi's disease, also known as Purpura annularis telangiectodes of Majocchi is a well-recognized but uncommon skin condition characterized by purple/bluish-red 1- to 3-cm annular patches composed of dark red telangiectases with petechiae. The name Majocchi's comes from the Professor Domenico Majocchi who first discovered the disorder in 1883. Domenico Majocchi was a professor of dermatology at the University of Parma and later the University of Bologna. Majocchi's disease can be defined as an infection of the dermal and subcutaneous tissues due to a fungal mold infection on the cutaneous layer of the skin. The most common dermatophyte is called Trichophyton rubrum. This disease can affect both immunocompetent and immunocompromised hosts. However, immunocompromised individuals have a higher risk.

References

External links

Steroid Rosacea

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[1] ttp://dermnetnz.org/acne/steroid-rosacea.html

[2] ttp://www.rosacea.net/steroid.html

[3] ttp://dermnetnz.org/acne/steroid-rosacea.html