Topical Corticosteroid Use and Misuse: Global Scenario and Role of International Topical Steroid Addiction Network (ITSAN)

Year

Country

Sample size

Findings/conclusion

Type of study

Reference

1969

England

14 cases

The fluorinated topical steroids should not be used in the treatment of rosacea, though the less potent hydrocortisone preparations appear harmless

Case series

[14]

1969

England

1 case

TCS may worsen the condition of Rosacea, but at times, it may be the cause of it

Case report

[15]

1972

Germany

8 cases

Rosacea-like dermatitis is to be regarded as a result of intolerance reaction of seborrhoeic skin to topically applied strong corticosteroids, such as betamethasone valerate and fluocinolone acetonide

Case series

[16]

1974

Philadelphia

10 cases

Regular use of topically applied fluorinated steroids produced a distinctive eruption consisting of persistent erythema, telangiectasia, atrophy, and occasional papules and pustules

Case series

[17]

1974

San Francisco

1 case

Prolonged use of potent TCs on the face can lead to long-term and disfiguring side effects

Case report

[18]

1976

Philadelphia

3 cases

Long-term application of fluorinated steroids to the face produces persistent disorders such as rosacea-like syndromes and acne. The genitalia are another off-limits area for dispensation of potent steroids

Case series

[19]

1976

Japan

25 cases

Hydrocortisone 17-butyrate was more useful as a topical medication than hydrocortisone acetate but gave rise to withdrawal rebound eruptions in some cases. And about 1 year was required to recover from atrophy and telangiectasias

Case series

[20]

1979

United Kingdom

259 cases

Out of 259 patients, all but nine of the patients acknowledged the use of potent TCs over long periods; in many cases, these were self-administered

Cross-sectional study

[21]

1979

United States

4 cases

Fluorinated gluco-corticosteroids should not be used on the face of infants and children

Case series

[22]

1991

Taiwan

23 cases

The diminution in stratum corneum lipids and pro-fillagrin and fillagrin in steroid-treated skin may play an important role in the clinical manifestations of scaling and dryness of the skin in patients suffering from the rebound phenomenon after stopping TCs

Case series

[23]

1999

Rapaport

California and Pennsylvania

100 cases

Complete stoppage is the only treatment of topical corticosteroid addiction. No additional treatment is required once the complete remission has been obtained after TC abuse

Case series

[24]

1999

Rapaport

California and Pennsylvania

12 cases

TC preparations when used postoperatively in patients experiencing peeling and resurfacing can cause prolonged erythema, dermatitis, burning, and telangiectasias, due to vasoconstriction/vasodilatation secondary to the corticosteroids through a non-intact barrier

Case series

[25]

2006

India

5 cases

The development of steroid dermatitis due to self-use of local steroid as cosmetic cream is frequent, and this is not only merely a medical problem but also a social problem

Case series

[26]

2006

South Africa

66 TCs selling vendors

There is extensive sale of illegal and unregistered topical corticosteroid creams on the KwaZulu-Natal street markets.

Furthermore, these products are being stored incorrectly leading to a decrease in the active ingredient and emergence of a degradation product

Cross-sectional study

[27]

2006

Iraq

1780 cases

140 (7.9%) had misused topical corticosteroids.

The main burden of responsibility for the misuse of topical corticosteroids was put on paramedical personnel and the patient (plus friends or family)

Cross-sectional study

[28]

2011

India

200 cases

Majority of patients were using potent (class II) topical steroids for trivial facial dermatoses. The common adverse effects were erythema, telangiectasia, xerosis, hyperpigmentation, photosensitivity, and rebound phenomenon

Cross-sectional study

[29]

A number of studies on this issue have been published from India which are discussed in the previous chapters pertaining to Indian Scenario of TC abuse. A prospective, multicentric study from India concluded that in patients with TC abuse, facial dermatosis was very common and TCs are mainly abused as a fairness cream [30].

There are many single case reports on varied side effects of TC misuse depicting various side effects of them.

Cushing syndrome and adrenocortical insufficiency have been reported in literature with long-term use of potent TCs [31, 32]. Prolonged application of topical steroids transiently suppresses the hypothalamic-pituitary-adrenal axis (HPA) leading to generalized infections and hepatosteatosis. Therefore, less potent steroids should be prescribed in infancy, and the adverse effects should be known to physicians and the parents. There has been another side to this issue, that people have developed phobias to TC treatment which has led to non-adherence and treatment failure in conditions like atopic dermatitis, where TCs are still the gold standard for treatment [33].

In China, 999 abuse—a misuse of topical cream called “999” containing dexamethasone acetate—has been reported. Parents were unaware of the potential contents of this topical and over used it in children, wherein one patient resulted in necrotizing fasciitis due to inappropriate use on ulcer [34].

A literature from China showed that the uncontrolled use of topical steroids over the face has led to various symptoms like dermatitis, acne rosacea, angiotelectasia, and dermotrophia/hyperpigmentation constitutively termed as facial corticosteroid addictive dermatitis (FCAD) [35].

Furthermore, neuropsychiatric manifestations have been reported due to misuse of clobetasol propionate [36].

34.3 About ITSAN and Various Organizations Against TC Misuse

Globally, a number of organizations have come up to tackle this sensitive issue of TC misuse and abuse.

From India, the IADVL Task Force Against Topical Steroid Abuse (ITATSA) has come up strongly against this problem [37]. ITATSA is a special task force created by the Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) to look into issues related to TC abuse. It has raised the issue of TC misuse at various fronts including physicians, manufactures, pharmaceutical companies, and regulators.

There are few more associations working on it like National Eczema Association [38], Eczema Association of UK [39], Eczema Association of New Zealand [40], and Eczema Association of Australasia [41].

A very promising and effective network has been formed internationally against this issue, named as International Topical Steroid Addiction Network (ITSAN) [42]. We will be learning about ITSAN in detail.

34.3.1 Brief Profile of ITSAN

The International Topical Steroid Addiction Network (ITSAN) is a nonprofit charity based in the United States and formed to raise awareness about a condition called Red Skin Syndrome (RSS), also known as Topical Steroid Addiction or Topical Steroid Withdrawal Syndrome.

In July 2009, Red Skin Syndrome sufferer Kelly Palace created the website “AddictedSkin.com” based on her own topical steroid withdrawal experience. The website featured her story with photos, as well as peer-reviewed, scholarly journal articles about topical steroid addiction and withdrawal. This website quickly evolved into an online support community.

In January 2012, Palace changed AddictedSkin.com to ITSAN.org and filed for nonprofit charity status with her former dermatologist, Dr. Marvin Rapaport, as cofounder. The International Topical Steroid Addiction Network was granted 501 c 3 nonprofit status in the United States on February 3, 2012. Dr. Rapaport left ITSAN in June 2013, and Palace continued as ITSAN president until January 2015. JoAnne VanDyke then took over as the current president of ITSAN, joined by a volunteer board of directors.

ITSAN Red Skin Syndrome Support has since expanded into a vast network of RSS sufferers from all over the world, communicating in the online forum and Facebook groups, as well as corresponding via email. ITSAN also holds patient conferences where caregivers, sufferers, and family members meet together to gain support in person.

ITSAN board members volunteer many hours creating educational materials, networking with healthcare providers, connecting with fellow patient advocacy organizations, traveling to conferences, and offering support to members suffering from Red Skin Syndrome.

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