Indian Journal of Dermatology
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ORIGINAL ARTICLE
Year : 2016  |  Volume : 61  |  Issue : 6  |  Page : 618-621
Topical steroid awareness and abuse: A prospective study among dermatology outpatients


Department of Dermatology, STD and Leprosy, Sapthagiri Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, India

Date of Web Publication9-Nov-2016

Correspondence Address:
T S Nagesh
No. 1586, "Niharika," 17th "A" Main, 1st Stage, 5th Block, HBR Layout, Bengaluru - 560 043, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.193666

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   Abstract 

Background: Topical steroids are one of the most commonly abused drugs. There are only a few studies available which have highlighted the severity of this problem in India. However, these studies have concentrated mainly on the topical steroid abuse and its side effects over the face. Aims: The aim of this study was to know the awareness among the people about various commonly available topical steroids and their combinations irrespective of usage and to know the extent of misuse of these drugs. Along with this, we also tried to find the source of recommendation of these medicines which will help to sensitize people about this menace. Materials and Methods: This was a prospective, questionnaire-based study done at a tertiary care hospital. A total of 1000 adult patients attending the dermatology outpatient department were administered a questionnaire about awareness and usage of topical steroid and its combinations. Results: A total of 1000 adult patients were included in the study, out of which 809 (80.9%) patients had heard about at least one of the topical steroids or its combinations mentioned in the questionnaire. Six hundred and twelve (61.2%) patients had used these creams. Acne and pigmentation were the most common indications for which topical steroid was used. These medicines were recommended by general practitioners in 302 (49.5%) patients and pharmacists in 71 (11.6%) patients. Totally, 318 (51.9%) patients complained of some form of side effect after using these creams. Aggravation of the symptoms and increased pigmentation were the most common adverse effects. Conclusion: Misuse of topical steroids not just over the face but also as a cream for any skin problem is quite common. Most of the times, it is recommended by general practitioners or pharmacists. It is very important to sensitize these people about the possible complications of these drugs and the extent of problem the society is facing because of irrational and unregulated use of these drugs.


Keywords: Awareness, misuse, topical steroid


How to cite this article:
Nagesh T S, Akhilesh A. Topical steroid awareness and abuse: A prospective study among dermatology outpatients. Indian J Dermatol 2016;61:618-21

How to cite this URL:
Nagesh T S, Akhilesh A. Topical steroid awareness and abuse: A prospective study among dermatology outpatients. Indian J Dermatol [serial online] 2016 [cited 2019 Jun 17];61:618-21. Available from: http://www.e-ijd.org/text.asp?2016/61/6/618/193666

What was known?
Topical steroid-dependent face is a common condition resulting from misuse of topical steroids over the face which may lead to erythema, burning and scaling.



   Introduction Top


Topical steroids are one of the most commonly used drugs in dermatology. The common indications are conditions such as psoriasis, lichen planus, eczema, lichen simplex chronicus, and other steroid-responsive dermatoses. However, because of their property of producing bleaching and anti-inflammatory effect, they have been misused frequently. They are misused for varied indications such as acne, pigmentation, fungal infection, pruritus, and many a times as a cosmetic or a skin cream for any type of rash. The main reason for such misuse in our country is its free availability as an over-the-counter (OTC) medication. Furthermore, topical steroids are available in various irrational combinations which cause more damage to the skin. There are studies which have tried to highlight the various side effects and harm caused by misuse of topical steroids and its combinations. These studies have tried to bring to the notice of regulatory authorities about the damage caused by the free availability of these creams. In this study, we have tried to find out the awareness among patients about these drugs and also as to how many of them have used these medicines. We also have tried to know the source of prescription for these creams.


   Materials and Methods Top


This was a prospective study conducted at the Dermatology Outpatient Department (OPD) in a tertiary care hospital. The Institutional Ethics Committee clearance was taken before starting the study. A total of 1000 adult patients attending the Dermatology OPD were included in the study. Each patient attending the Dermatology OPD irrespective of their complaints was asked to fill up a questionnaire. The questions mainly tried to find out if the patients had ever heard about the commonly abused topical steroids and its combinations (betnovate®0, skinlite, melacare, panderm, fourderm, lobate GM, quadriderm) in our area and if they had used any of those creams. They were also asked about usage of any other creams other than the ones mentioned in the list. Furthermore, they were asked regarding who suggested those creams to them, the duration of usage, and if they noticed any side effect. Patients <18 years and those not willing to answer the questionnaire were excluded from the study.


   Results Top


A total of 1000 adult patients (male: 360, female: 640) were included in the study. Eight hundred and nine patients out of the 1000 patients had heard about at least one of the topical steroids mentioned in the questionnaire. Betnovate was the most commonly known product (597 patients). Six hundred and twelve patients (400 female and 212 male) had used the topical steroid or its combination for various indications [Table 1].
Table 1: Brand names of the topical steroid-containing products


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The indications for which these medicines were used included acne (30.2%), allergy (14.8%), pigmentation (11.4%), boils (0.3%), eczema (0.98%), fairness (as cosmetic 10.8%), fungal infections (3.4%), injury (3.5%), itching (11.7%), oily skin (0.65%), skin rashes (7.1%), white patches (1.9%), and burns (0.32%). Acne was the most common indication for which topical steroid was used, followed by allergy and rashes. Around 66 (10.8%) patients were using these medicines as a cosmetic for fairness and 70 (11.4%) patients were using it to remove pigmentation due to various reasons. Overall 52.4% of patients were using these creams mainly over the face and rest of them were using it over other parts of the body as a general skin cream for any rashes.

These medicines were prescribed by general practitioners in 302 (49.5%) patients. Friends had suggested these medicines in 191 (31.2%) patients, followed by pharmacists in 71 (11.6%) patients. Others like family members had given the creams in 39 (6.3%) patients.

The duration of the usage of these creams varied from 1 day to 10 years. Around 383 (62.5%) patients had used these creams for a duration varying from 1 week to 3 months. One hundred and seven (17.4%) patients had used these creams from 3 months to 2 years.

Three hundred and eighteen (51.9%) patients complained of some form of side effect after using these creams. Aggravation of the symptoms was also considered as a side effect for the study. One hundred and twenty-seven patients complained of aggravation of symptoms, 65 patients complained of increased pigmentation [Figure 1], 26 patients developed pimples [Figure 2], and redness and irritation was seen in 74 patients. Thirteen patients complained of striae. Other minor side effects included white patches, burning sensation, and no improvement of the skin problem [Table 2].
Figure 1: Pigmentation due to use of topical steroid

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Figure 2: Aggravation of acne

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Table 2: Adverse effects as complained by the patients using topical steroids


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   Discussion Top


Topical steroids were first used in dermatology by Sulzberger and Witten in 1952 when they published an article on the effect of topically applied compound F in selected dermatoses. [1] Subsequently, various other topical steroids were introduced with varying potencies and formulations. The availability of these drugs revolutionized the treatment of various steroid responsive dermatoses. Topical steroids have greatly contributed to the dermatologist's ability to effectively treat several difficult dermatoses. [2] They were hailed as a panacea for all ills by physicians and patients and gained rapid popularity. [3] Topical steroids are one of the most commonly used drugs by dermatologists worldwide. [4],[5]

However, the dramatic symptomatic relief from these medications led to misuse and abuse of these drugs by both nondermatologists and patients. Topical steroids were used by many patients as fairness or cosmetic creams. [6],[7] The rampant misuse and abuse of these medicines led to the development of various side effects, both cutaneous and systemic. [7],[8],[9]

Various studies have tried to highlight the menace caused by the use of topical steroids. [10],[11] A multicentric study by Saraswat et al. has also been done to highlight the topical steroid abuse on the face. [10] Around 2296 patients with facial dermatoses were screened, of which 433 patients were using topical steroids. In our study, we have included 1000 adult patients attending dermatology OPD irrespective of their skin complaints. We have tried to find out how many patients have heard about any of the common topical steroids available OTC in our area and also how many of them have used these creams.

Around 809 patients (80.9%) had heard of at least one of the topical steroids or its combinations. Six hundred and twelve (61.2%) patients had used one of the steroids or steroid combinations for a duration varying from 1 day to 10 years. The common indications for which steroid was used were acne, fairness (as cosmetic), pigmentation, and allergy. The findings are similar to the study conducted by Saraswat et al. and Dey. [10],[11] An Iraqi study showed 7.9% of patients using topical steroid for similar indications. [12]

In our study, 302 (49.5%) patients who had used the steroid had received the prescription from a doctor. In the study by Saraswat et al., 41% of the patients had received the recommendation from a doctor. In the present study, 301 (49%) patients were advised to use these medicines by pharmacists, friends, and relatives. However, most of the time, general practitioners and doctors from alternative medicine had prescribed these medicines. General practitioners and pharmacists are often the first point of contact for most of the patients. Training and sensitizing them regarding steroid abuse would help in reducing the incidence of topical steroid-related side effects.

The common side effects found in our study were acne, pigmentation, redness, itching, burning sensation, striae, and aggravation of existing skin problem. These are similar to the findings by Saraswat et al. and Dey. The nature of side effect correlated with the duration of the usage of topical steroid. However, many of our patients were not aware of the fact that the problems they were facing were due to the long-term use of steroids.


   Conclusion Top


From the findings of our study and other studies, we would like to conclude that topical steroid abuse is rampant in our population. The reason for this varies from wrong prescription, dubious marketing by pharmaceutical companies, free availability of these medicines as OTC drugs, and lack of regulations regarding the manufacturing of irrational combinations. As general practitioners and pharmacists are recommending these products in majority of the cases, it is very important to sensitize these people about the possible complications of these drugs and the extent of problem the society is facing because of irrational and unregulated use of these drugs. Our study aims to highlight the misuse of steroids and its combination anywhere on the body. Our study was an outpatient-based study, and further larger studies will give a clearer picture about the magnitude of the steroid abuse.

Acknowledgment

We would like to thank Dr. Savitha AS and Dr. Priyadarshini M for helping us in conducting the study and preparing the manuscript.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Sulzberger MB, Witten VH. The effect of topically applied compound F in selected dermatoses. J Invest Dermatol 1952;19:101-2.  Back to cited text no. 1
    
2.
Rathi SK, D'Souza P. Rational and ethical use of topical corticosteroids based on safety and efficacy. Indian J Dermatol 2012;57:251-9.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Coondoo A. Topical corticosteroid misuse: The Indian scenario. Indian J Dermatol 2014;59:451-5.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Stern RS. The pattern of topical corticosteroid prescribing in the United States, 1989-1991. J Am Acad Dermatol 1996;35(2 Pt 1):183-6.  Back to cited text no. 4
    
5.
Kumar AM, Noushad PP, Shailaja K, Jayasutha J, Ramasamy C. A study on drug prescribing pattern and use of corticosteroids in dermatological conditions at tertiary care teaching hospital. Int J Pharm Sci Rev Res 2011;9:132-5.  Back to cited text no. 5
    
6.
Nnoruka E, Okoye O. Topical steroid abuse: Its use as a depigmenting agent. J Natl Med Assoc 2006;98:934-9.  Back to cited text no. 6
    
7.
Rathi S. Abuse of topical steroid as cosmetic cream: A social background of steroid dermatitis. Indian J Dermatol 2006;51:154-5.  Back to cited text no. 7
  Medknow Journal  
8.
Hengge UR, Ruzicka T, Schwartz RA, Cork MJ. Adverse effects of topical glucocorticosteroids. J Am Acad Dermatol 2006;54:1-18.  Back to cited text no. 8
    
9.
Dhar S, Seth J, Parikh D. Systemic side-effects of topical corticosteroids. Indian J Dermatol 2014;59:460-4.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.
Saraswat A, Lahiri K, Chatterjee M, Barua S, Coondoo A, Mittal A, et al. Topical corticosteroid abuse on the face: A prospective, multicenter study of dermatology outpatients. Indian J Dermatol Venereol Leprol 2011;77:160-6.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.
Dey VK. Misuse of topical corticosteroids: A clinical study of adverse effects. Indian Dermatol Online J 2014;5:436-40.  Back to cited text no. 11
  Medknow Journal  
12.
Al-Dhalimi MA, Aljawahiry N. Misuse of topical corticosteroids: A clinical study in an Iraqi hospital. East Mediterr Health J 2006;12:847-52.  Back to cited text no. 12
    

What is new?
Topical steroid abuse is not only limited to the face but also over the rest of the body. Lack of awareness among general practitioners and pharmacists may further worsen the problem.


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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