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Morbidity of over-the-counter topical steroids

2005; Elsevier BV; Volume: 54; Issue: 1 Linguagem: Inglês

10.1016/j.jaad.2005.08.038

1097-6787

Brandie Tackett, Mary C. Smith, Susan Nedorost,

Herpesvirus Infections and Treatments

To the Editor: We read with interest the article entitled “Consumers appropriately self-treat based on labeling for over-the-counter hydrocortisone.”1Ellis C.N. Pillitteri J.L. Kyle T.K. Ertischek M.D. Burton S.L. Shiffman S. Consumers appropriately self-treat based on labeling for over-the-counter hydrocortisone.J Am Acad Dermatol. 2005; 53: 41-51Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar The Food and Drug Administration is considering over-the-counter status for topical steroids that do not induce adrenal axis suppression. This article emphasizes that over-the-counter usage of hydrocortisone is generally safe and appropriate. However, we are greatly concerned with the potential for topical steroid use on facial skin, which may result in steroid-induced rosacea and topical steroid addiction. After observation of long-term facial application of even low-dose corticosteroids, we have seen many adults and children with a rosacea diathesis in whom severe burning and itching develop, along with bright red papules and nodules. This may occur after long-term application of even low-potency topical corticosteroids.2Guin J. Complications of topical hydrocortisone.J Am Acad Dermatol. 1981; 4: 417-422Abstract Full Text PDF PubMed Scopus (40) Google Scholar Steroid-induced rosacea clearly occurs after the use of topical corticosteroids that have never been associated with adrenal suppression. Application of topical corticosteroids causes immediate vasoconstriction and reduces the redness seen in rosacea and many other skin conditions. However, when patients discontinue usage of the topical corticosteroid, symptoms immediately reappear, and the symptoms are often much worse than those seen in the original condition. Murine models support the notion that withdrawal of topical corticosteroids can increase allergic and irritant contact responses and increase keratinocyte production of neurotransmitters.3Katayama I. Bae S. Hamasaki Y. Igawa K. Miyazaki Y. Yokozeki H. et al.Stress response, tachykinin, and cutaneous inflammation.J Investig Dermatol Symp Proc. 2001; 6: 81-86Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar When symptoms reemerge, the patient begins using the topical corticosteroid again, and it is difficult even for a health professional to convince the patient of the necessity of discontinuing the medication. The recovery period from steroid addiction can take several months, requiring frequent support from health care professionals.4Rapoport M. Rapoport V. Eyelid dermatitis to red face syndrome to cure: clinical experience in 100 cases.J Am Acad Dermatol. 1999; 41: 435-442Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar In this article, Ellis et al demonstrate that 20% of adults in the general population have used over-the-counter hydrocortisone and that 0.15% have used it for more than a year. We would be interested to know whether these patients were using the steroid on facial skin, as this subgroup likely represents the disease population experiencing steroid rosacea, steroid addiction, or both. Over-the-counter availability of more potent steroids is likely to increase both the prevalence and the severity of this dependency cycle. Given the widespread usage of topical steroids documented by Ellis et al, this will result in many affected patients. We expect that physicians will see many more cases of this miserable condition if corticosteroids, in addition to hydrocortisone, are permitted for sale without prescription. We urge the Food and Drug Administration to consider both the morbidity and the increase in health care costs associated with steroid-induced rosacea.