Sulzberger and Witten in 1952 introduced compound F (hydrocortisone), the first topical steroid to the world of dermatology [1]. Hydrocortisone and later, its most more potent analogues seemed like the holy grail of dermatology, a means to quell inflammation of the integument [2]. A decade passed before the adverse events first report of adverse events surfaced [3]. Another decade passed before addiction to topical steroids was reported in 1973 [4]. Kligman and Frosch [5] coined the term “steroid addiction” and gave a poignant description of the physical, psychological and social trauma that patients “hooked” to topical steroids go through.

A spate of articles on misuse and addiction continued to pour in over the next four decades [6–16]. The unabated accumulation of literature on the subject is merely a sign of the growing menace of topical steroid abuse.

Drug control authorities of a country are responsible for issuing drug licenses for manufacture and sale and approving indications and that can be treated with the drug. They may also decide to cap the price of certain drugs. Laws of the land decide which drugs can be sold over-the-counter, without prescriptions. They also decide which drugs may be advertised to lay people, if at all. The law machinery needs to implement the laws and check how stringently rules are being honored.

In the context of topical steroids, the controversy lies around issuing licenses to irrational fixed drug combinations that contain antibiotics and antifungals, in addition to steroid molecules. Use of mid-potent steroids like mometasone in modified Kligman’s formula is also a case in point.

Failure of regulatory authorities in India has no small role to play in the topical steroid menace that the nation is fighting. The major chinks in the armor of relevant law are:

Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) has constituted a task force, the IADVL Taskforce Against Topical Steroid Abuse (ITATSA) to fight the growing menace of topical steroid abuse.

Topical steroid-antifungal ± antibacterial combinations account for 43% of all topical steroid preparations sold, contributing to a staggering Rs. 753 crore, out of the total Rs. 1.716 billion of all topical steroid sales [23]. Most of these preparations are irrational and unscientific. Widespread use of topical steroids in conjunction with antifungals has led to the emergence of recalcitrant and atypical fungal infections [24]. The use of these FDCs has become so commonplace that most of the dermatophytosis seen by dermatologists is now steroid modified. As patients feel relief within just a few days of usage of these creams, they stop the topical preparation. Local immune suppression caused by the steroid component of the cream allows spread of the infection. Intermittent exposure to antifungals makes the organism resistant to its action. The medication is restarted when the itching and redness return, usually with a vengeance. Steroid part of the cream provides some symptom relief but the antifungal fails to do any good, resulting in the infection spreading rapidly. This vicious cycle has made treating steroid modified tinea a frustrating and expensive exercise. As it is contagious, family members frequently acquire recalcitrant tinea and end up spending money they can ill-afford to.

Unless urgent action is initiated, irrational topical steroid containing FDCs are all banned and strong legislation implemented to stop the unsupervised sale of steroid creams, this nightmare will turn more sinister. It might be years before the sensitivity of dermatophytes returns to normal even if effective steps are taken.