| Abstract|| |
Background: A lot of cosmetic and Ayurvedic products containing unlabeled depigmenting agent and steroids are available readily over the counter sale. The side effects of these products are not documented and can lead to adverse effects of continuous usage. Objective: By this study, we aimed to find out the true nature of the above problem and it's implication in the Indian rural scenario. Methodology: All patients attending dermatology department during the period of 3 months from May to June 2013 for skin diseases were enquired about unsupervised use of any cosmetic product on their facial skin, duration of use, any side effect experienced through the prescribed questionnaire. Results: Total 50 patients were recruited for the study. Out of which, 48% were males and 52% were females. Seventy-four percent of people had applied topical products/steroids in an attempt of attainment of fair complexion, 14% for melasma, 8% for acne induced hyperpigmentation, and 4% for dark circles. About 80% people had obtained one or the other products over the counter sale, 8% had followed the attractive advertisements, 8% had started the application on the recommendation of friends/family while only 4% people had correctly gone through the proper channel to consult a dermatologist. Conclusion: The problem of topical products or steroids abuse is rampant and significant, and unless and until immediate steps are taken to root out this problem from our setup, the condition will become worse all the more.
Keywords: Dermatoses, over the counter, tachyphylaxis, topical steroid
|How to cite this article:|
Sinha A, Kar S, Yadav N, Madke B. Prevalence of topical steroid misuse among rural masses. Indian J Dermatol 2016;61:119
What was known?
Despite patent protection and sales regulation of compounds such as steroids, they are readily available at affordable prices from pharmaceutical stores over the counter sale even without a doctor′s prescription and when prescribed by a registered physician is indiscriminately used even after the prescribed stipulated tenure is over. The side effects of these products can lead to adverse effects of continuous usage.
| Introduction|| |
Treatment of skin diseases was revolutionized with the advent of anti-inflammatory properties of corticosteroids. Steroids are anti-inflammatory agents used for the treatment of steroid responsive dermatoses.  Topical corticosteroids (TCs) are one of the most extensively used therapeutic modalities in modern dermatologic practice. Inappropriate or incorrect use leads to an initial improvement in the symptoms followed by tachyphylaxis. Besides their anti-inflammatory actions, TC also possess anti-pruritic, atrophogenic, melanopenic, sex-hormone-like and immunosuppressive effects on the skin leading to significant local adverse effects if TCs are not used judiciously. 
Use of topical steroids as a skin lightening agent is on the alarming rise and has been a matter of concern for dermatologists across the globe. Steroid containing skin lightening agents are easily available over the counter which has led to rampant misuse of these agents. Furthermore, the abuse of topical steroids is worsened due to irrational prescription by family physicians for nonindicated problems.
Aims and objectives
The objective of this study was to evaluate the prevalence of steroid misuse among rural masses.
| Methodology|| |
The study was conducted in the outpatient section of dermatology department of a Rural Tertiary Teaching Hospital in Central India. Patients of all ages and either sex were recruited for this study. A validated questionnaire was administered to all the eligible participants eliciting the nature of topical products/steroids used, duration and source of prescription. The patients were examined for any cutaneous side effects of the topical steroid or any other product being applied such as skin atrophy, depigmentation erythema, telangiectasia, and were treated accordingly.
Three months (May 2013 to July 2013).
All patients attending dermatology department for skin diseases were enquired about the unsupervised use of any cosmetic product on their facial skin. In the event of a positive answer, they were shown a photographic folder containing the packets/tubes of most commonly used topical steroids and depigmenting agents available in the market and were enquired about the particular details of the usage of the agent concerned via the prescribed questionnaire. Full questionnaires were only filled for those answering "yes" to the screening question.
Patients are not consenting to the questionnaire were excluded from the study.
Chi-squared and Fisher exact tests were used for statistical analysis, with a significant threshold fixed at 5% (P < 0.05).
| Results|| |
Total 50 patients were recruited for the study. Out of which 24 were males (48%) and 26 were females (52%). The mean age of the screening group was 24.2 years (range: 12-44 years) with the majority of people in the age group of 20-30 years.
31 (62%) people were unmarried, and 19 (38%) were married. Out of all the subjects screened 15 (30%) were educated up to 10 th standard, 27 (54%) were educated up to 12 th standard, and 8 (16%) subjects were graduates.
A major group, (46, i.e. 92%) of the people, were Hindu, while Muslims and Christians were on the minority (2 each, i.e. 4% in each category). Thirty-one students (i.e. 62%) were enrolled for the study, while 4 (i.e. 8%) subjects were farmer by occupation, 3 (i.e. 8%) were laborers, 11 (i.e. 22%) were housewives, and 1 (i.e. 2%) was in private service.
All the 50 patients in the study group presented with the history of usage of depigmenting agents out of which 23 (i.e. 46%) subjects presented with the application of CREAM A, 5 (i.e. 10%) people with CREAM B application, 4 (i.e. 8%) people with CREAM C, 3 (i.e. 6%) people with CREAM D, 3 (i.e. 6%) people with usage of CREAM E, 3 (i.e. 6%) people with CREAM F, and 1 person (i.e. 2%) each with the usage of CREAM G, CREAM H, CREAM I, CREAM J, CREAM K, CREAM L, and lastly CREAM M. All these products contain topical steroids.
A large proportion 37 (74%) of people had taken the mentioned above topical products/steroids in an attempt of attainment of fair complexion, 7 (14%) for melasma, 4 (8%) for acne induced hyperpigmentation, and 2 (4%) for dark circles in and around areas of the face.
About 40 (80%) people had obtained one or the other products on the own (over the counter sale), 4 (8%) of the had followed the attractive advertisements, 4 (8%) had started the application on the recommendation of friends/family while only a small fraction comprising 2 (4%) people had correctly gone through the proper channel to consult a dermatologist prior to the application of a topical agent of their concern.
25 (50%) people had been using the product concerned over a period of 1-year, 10 (20%) of them over a period of 3 months, 6 (12%) of them over a period of 1-month, 2 (4%) of them over a period of 9 months, 1 (2%) around for a period of 1-year, and 6 (12%) over a period of 6 months.
26 (52%) people had the history of application of one of the above mentioned product once a day, 22 (44%) for 2 times a day and 2 (0.04%) had a history of application of the product concerned with a frequency of 4 times a day.
Forty-nine out of 50 (98%) patients presented with the history of application of the topical product on face (9%) while only 1 (i.e. 2%) subject gave the history of 18% application (by rule of 9) due to a combined application on face and other body areas (adding a total of 18%).
An average of Rs. 79.46 was spent by all the participant of the study on topical medication per month (range Rs. 25-325) out of which 43 (i.e. 86%) did not present with any other related complaints but the remaining 7 (i.e. 14%) did (4 presented with hypertension, 2 presented with other systemic illness, and 1 presented with diabetes mellitus).
Taking the general examination of the patients into account, 37 (i.e. 74%) of them were of good nutritional status and 13 (i.e. 26%) of them were of average nutritional status. Thirty-nine (i.e. 78%) of them were of average built, 9 (i.e. 18%) of them were of thin built and 2 (i.e. 4%) of them were obese. Vitals of all the patients undertaken for the study were stable though 8 (i.e. 16%) of them appeared pale and 3 (i.e. 6%) of them were hypertensive.
| Discussion|| |
The eye-catching posters, advertisement on television allures people toward the indiscriminate usage of topical products. This problem gets worsened as the patient has an easy access for an indefinite number of refills of a single prescription/topical product from the local chemist (over the counter sale) and cosmetic shop leading to the production of adverse effects and sometimes dependence or addiction to these topical products. In India, the problem is even more pathetic, wherein anyone has an easy access to topical products/steroids without the need to get it prescribed by a registered medical practitioner. Moreover, these topical products/steroids have acquired a reputation as an anti-acne, anti-blemish, and fairness creams in the general population, not only among the dark people but also the fairer ones who want to be fairer than before.  This study clearly reveals the problem of topical products/steroid misuse on the face.
Studies concerning the similar objectives have been reported from China , and Iraq  where abuse appears to be very widespread. The Iraqi study reported that 7.9% of the dermatology clinic attendees had misused topical products/steroids. Most topical products/steroids abusers in that study were in the 10-19 years age group, whereas, in our study, we found that most patients were in the 20-30 years age group. However, our data were limited to usage on the face, whereas on the contrary the Iraqi study reported topical products/steroids abuse anywhere on the body.
In a study concerning topical products/steroids misuse from China,  the proportion of patients applying topical products/steroids on face without any underlying dermatosis in their study was 28.5% as compared to our study where it was 74%. Studies concerning the misuse of topical products/steroids have been well reported from Africa  though Asian countries are not well far behind in this regard. , Even developed countries like the USA are confronting this problem. 
Topical products/steroids addiction and side effects can be treated and results in significant improvement in the quality of life of these patients.  Treatment of facial adverse effects of topical products/steroids focuses on complete cessation of usage. In case of addiction, progressively less potent topical products/steroids are introduced over a period of weeks to months and the dose is gradually tapered off. Unpleasant symptoms, including, stinging, pruritus, and photosensitivity, are treated using emollients and sunscreens. Systemic agents include tetracyclines, isotretinoin, nonsteroidal anti-inflammatory drugs, and antihistamines.
In our study, only 4% of the patients had received topical products/steroids prescriptions from medical practitioners while 80% of people obtained it over the counter sale, 8% as a recommendation from friend/family and the remaining 8% were allured from attractive advertisements. In the 2 patients who were using dermatologist prescribed topical products/steroids, the duration of use was not mentioned in the prescription and almost all the patients had continued on the indiscriminate usage of these topical products/steroids even after the concerned ailment was treated.
In almost all patients who were using these topical products/steroids, it had been recommended by a nonphysician. Mometasone, hydroquinone, and tretinoin-containing skin-lightening agents usage have recently geared up and become very popular in our country resulting in their aggressive marketing by numerous pharmaceutical companies and their prescription not just by dermatologists but all physicians resulting in their widespread abuse.
A trend noted in our study was the high incidence of topical products/steroid usage in the younger generation. A subjective feeling to appear good looking and peer pressure probably drive these subjects toward the procurement of topical products/steroids over the counter sale and indiscriminate use of these products.
This study revealed the pathetic misuse of topical products and steroids that is becoming endemic at an increasing rate in the Indian rural setup. Even countries like England, are facing the problem of overuse and misuse of these products by the commoners.  In India, it seems that the free availability of these topical products and steroids without a prescription from a registered physician has allowed many of these drugs to become household names, where they are hardly regarded as drugs anymore.
This study was done under short-term studentship program of ICMR.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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What is new?
Presently due to faulty laws in the marketing setup, many pharmaceutical companies are advertising even clobetasol containing creams on the television and other media as a result of which they are being obtained as over the counter sale products. As indicated by this study, the problem of topical products which contain unlabeled steroids and steroids abuse is rampant and significant, and unless and until immediate steps are taken to root out this problem from our setup, the condition will become worse all the more.