Topical Corticosteroid Abuse in Nepal: Scenario

Fig. 18.1

List of topical corticosteroids according to their potency [1]

Common conditions where topical steroids are prescribed (alone or in combination with other medications) [1] are as follows:

Psoriasis

Atopic dermatitis

Seborrheic dermatitis

Intertrigo

Nummular eczema

Lichen simplex chronicus

Lichen planus

Allergic contact dermatitis

Papular urticaria

Common adverse effects of topical steroids [1–3]:

Skin atrophy

Acneiform reactions, steroid-induced acne/rosacea/perioral dermatitis

Hypertrichosis

Pigmentary changes

Development of infections

Steroid-induced dermatosis

18.2 Current Scenario

This chapter is an overview of the current scenario that we dermatologists practising in different parts of Nepal deal with in our day-to-day practice.

Nepal is a developing country, and at present, there are no proper health insurance plans readily accessible to all citizens. Anyone who has health issues hesitates to visit a doctor. Rather than treating any problem at its initial stage and preventing complications, patients do the pre-doctor trial method. One of the major problems this tendency has led to is the increase in steroid abuse and steroid-induced dermatosis.

Many topical preparations are sold in pharmacy as an over-the-counter medication (OTC), i.e. these can be given to patients without doctor prescription. There are no definite guidelines for OTC and prescription medication. Hence, when there are several problems, especially in relation to dermatology such as itching, urticaria and pigmentation, etc., people take the advice of the person in pharmacy and without any proper examination start OTC. Currently one of the most frequently selling OTC products is topical steroids. In the lack of proper law and also absence of licenced pharmacists, topical steroids are sold like common household products (it would not be wrong to say that it is sold like toothpaste).

18.3 Patient Perspective

Also from the patients’ side since they do not know about the strength, effects, side effects and contraindications of topical steroids, they use it. As we all know, topical steroids reduce inflammation: the patient feels relieved after its use, no matter what the real problem is, and instead of consulting the experts, they continue using it.

So be it, knowingly or unknowingly topical steroids are being abused by the person in pharmacy as well as the patients themselves. Several times there are also unlabelled, non-licenced creams and other topical preparations which are sold in the market, beauty parlour, cosmetic shops and advertising agencies claiming to be herbal, special formulations or authentic skin creams with no medications. Several times even the topical cosmetic creams sometimes repack steroids or mix steroids with cosmetic creams and label them as being pure cosmetics.

But no matter who is abusing it or why the trend is increasing, ultimately the patient suffers! When the indications are not correct, usually steroids mask the real problem; they give temporary relief, and the patient gets habituated to its use. There is development of steroid dependency; whenever the patient uses steroid, there is relief from the problem, but once they try to stop it, either the problem comes back again or it even gets worse with other new problems.

Hereby, we shall discuss few such common scenarios: steroid-induced dermatosis due to steroid abuse.

18.4 Scenario

18.4.1 Case 1

A 23-year-old unmarried female who is living and working in Kathmandu as a sales girl in a supermarket noticed hyperpigmentation over her B/L cheeks and nose area; she asked her friend who had clearer skin and was told she was using some cream given to her at the pharmacy. Without giving it a second thought, she went to the pharmacy and asked if they had cream for her problem and was given mometasone furoate.

18.4.1.1 Problem

The person at the pharmacy was not a trained or licenced pharmacist; he was like any other shopkeeper, selling and making profit. There was no diagnosis, treatment was incorrect and no guidelines for its use were given.

18.4.1.2 Result

After few weeks since there was lightening of the pigmentation, she started using mometasone like a night cream. She was unaware of the harm that it would do in the long run. She also got complements from her friend that her skin was getting better. Weeks to months to years, then she developed ‘steroid dependency’.

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