Steroid Induced Rosacea is, sadly, one hot topic.

I know this because the blog posting Treating Steroid Induced Rosacea is one of the most visited pages on this site, and is currently approaching 1000 comments. Unfortunately many who find themselves suffering from steroid rosacea have to endure a prolonged withdrawal and recovery period.

This just published abstract relating to Steroid Induced Rosacea is interesting for a few reasons;

• The average period of treatment for these steroid using patients was 20 months.
• The majority were using potent steroids (but we also know that OTC Steroids can cause Steroid Rosacea).
• The majority were using steroids for what the authors claim to be trivial dermatoses.

Could it be the case that vanity is driving some of the suffering that occurs from steroid rosacea?

I wonder if anyone who is suffering from the angry red face of steroid withdrawal would be so quick to use steroids if they had known where it could lead?

The paper ends with the conclusion that oral antibiotics and topical tacrolimus (Protopic) is the treatment of choice.

Steroid-induced rosacea: a clinical study of 200 patients, Indian J Dermatol. 2011 Jan;56(1):30-2, Bhat YJ, Manzoor S, Qayoom S.

Department of Dermatology, SKIMS Medical College Hospital, Srinagar, Jammu and Kashmir

BACKGROUND: Topical corticosteroids were first introduced for use in 1951. Since then uncontrolled use (abuse) has caused many different reactions resembling rosacea – steroid dermatitis or rosacea. Multiple pathways including rebound vasodilatation and proinflammatory cytokine release have been proposed as the mechanism for such reactions.

AIM: The aim was to study the adverse effects of topical steroid abuse and the response to various treatment modalities.

MATERIALS AND METHODS: Two hundred patients with a history of topical steroid use on face for more than 1 month were studied clinically and various treatments tried.

RESULTS: The duration of topical corticosteroid use varied from 1 month to 20 years with an average of 19.76 months. 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. No significant change in laboratory investigations was seen.

CONCLUSION: A combination of oral antibiotics and topical tacrolimus is the treatment of choice for steroid-induced rosacea.

It is Time to Taper!

If you are using steroid creams regularly then this abstract should serve as some good advice to think about tapering off. Don’t withdraw cold turkey style, but taper off instead. See if you can find a doctor to support you.

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Promiseb Topical Cream has been found to be as effective as desonide cream 0.05% when treating facial dermatitis. This is an exciting finding, especially if the results can be replicated at large in the rosacea / seborrheic dermatitis community.

Rosacea sufferers are well advised to be careful with any form of steroids because it has been shown that even over the counter steroids can cause steroid induced rosacea.

Those using the Promiseb Cream, who experienced cleared symptoms after 14 days, were more likely to stay clear for another 14 days after ceasing, compared to the Desonide Cream. This result is encouraging as it suggests that the benefit from Promiseb is more sustainable compared to even low strength topical steroids. Thus it seems from this study that Promiseb is indeed a better treatment than Desonide for mild to moderate seborrheic dermatitis.

Promiseb Topical Cream (Sebclair) is a non-steroidal, prescription only cream for the treatment of seborrheic dermatitis. It has demonstrated anti-inflammatory and anti-fungal properties. Sebclair is approved for use in the European Union to treat seborrheic dermatitis. One of Sebclair’s (and now Promiseb’s) claims to fame is that it contains no corticosteroids or immunomodulating agents.

The ingredients of Sebclair are listed here: Sebclair for seborrheic dermatitis. See also the Promiseb Prescribing Information.

An investigator-blind, randomized, 4-week, parallel-group, multicenter pilot study to compare the safety and efficacy of a nonsteroidal cream (Promiseb Topical Cream) and desonide cream 0.05% in the twice-daily treatment of mild to moderate seborrheic dermatitis of the face.

Clin Dermatol. 2009 Nov-Dec;27(6 Suppl):S48-53., Elewski B.

The treatment of seborrheic dermatitis includes topical antifungal agents to eradicate Malassezia spp, corticosteroids, which treat the inflammatory component of the disease and keratolytics which remove scale and crust.

This study compared the efficacy of a nonsteroidal topical cream and a low-potency topical corticosteroid for the treatment of mild to moderate seborrheic dermatitis of the face in 77 volunteers randomized to twice-daily treatment with nonsteroidal cream or corticosteroid cream for up to 28 days. If the individual was rated clear by day 14, the study drug was collected and the participant was told not to use any topical products on the previously treated areas until after the 28-day follow-up visit.

Both treatments were similarly effective in reducing disease severity, with approximately 90% of participants clearing or almost clear during the study. Both treatments demonstrated significant reductions in erythema, scaling, and pruritus (P < .0001). Safety in both groups was rated as excellent in more than 90%.

Those using the nonsteroidal cream who cleared after 14 days of treatment were more likely to remain clear than were participants using the corticosteroid cream (P = .0173). [my emphasis]

Investigator global assessments of improvement found both study agents were essentially the same, and participants in both groups achieved clinically important improvement.

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A recent Rosacea News post listing the some preliminary user reviews for Clinique Redness Solutions was unclear on whether the Urgent Relief Cream contains cortisone.

Well the answer is yes, it does. This would suggest that this product is not suitable for long term use for rosacea sufferers.

It is not a surprise that a product that claims up soothe upset skin would contain cortisone. Cortisones have been the mainstay of dermatology relief products for many years.

Thanks to ratherbquiltn here are the full listing of ingredients for the Redness Solutions range.

Redness Solutions Urgent Relief Cream

active ingredient: hydrocortisone acetate 0.50%

ingredients: water/aqua/eau, cyclopentasiloxane, butyrospermum
parkii (shea butter), cetearyl alcohol, squalane, butylene glycol, glycerin, sucrose, isostearyl neopentanoate, avena sativa (oat) kernel extract, camellia sinensis (green tea) leaf extract, chamomilla recutita (matricaria), cetearyl glucoside, hydrogenated lecithin, cholesterol, linoleic acid, methyl glucose sesquistearate, sodium hyaluronate, tocopheryl acetate, carbomer, sodium chloride, stearic acid, disodium phosphate, potassium carbomer, citric acid, disodium edta, phenoxyethanol, sodium dehydroacetate.

Redness Solutions Daily Protective Base SPF15

This product is currently not available at the clinique.com web site.

active ingredients: titanium dioxide 6.40%, zinc oxide 2.00%

ingredients: water/aqua/eau, trioctyldodecyl citrate, cyclopentasiloxane, butylene glycol, c12-15 alkyl benzoate, steareth-2, stearyl dimethicone, tricaprylyl citrate, silica, barium sulfate, lecithin, sorbitan tristearate, aluminum stearate, sea whip extract, glyceryl stearate, tocopheryl acetate, peg-100 stearate, sucrose, pantethine, caffeine, octyldodecyl neopentanoate, ceteth-2, peg-40 stearate, dimethicone, cetearyl alcohol, glycosaminoglycans, peg/ppg-18/18 dimethicone, steareth-20, bisabolol, magnesium ascorbyl phosphate, polyglyceryl-6 polyricinoleate, phytosphingosine, sodium stearate, magnesium aluminum silicate, caprylyl glycol, isopropyl titanium triisostearate, stearic acid, hexylene glycol, xanthan gum, citric acid, disodium edta, bht, phenoxyethanol, iron oxides (ci 77491, ci 77492, ci 77499), chromium hydroxide green (ci 77289).

Redness Solutions Daily Relief Cream

ingredients: water/aqua/eau, cyclopentasiloxane, butyrospermum parkii (shea butter), cetearyl alcohol, hydrogenated polyisobutene, butylene glycol, glycerin, sucrose, isostearyl palmitate, peg-100 stearate, camellia sinensis (green tea) leaf extract, polygonum cuspidatum root extract, hordeum vulgare (barley) extract/extrait d’orge, triticum vulgare (wheat) germ extract, cetearyl glucoside, camellia sinensis (yellow tea) leaf extract, aspalathus linearis (red tea) leaf extract, saccharomyces lysate extract, methyl glucose sesquistearate, camellia sinensis (white tea) leaf extract, yeast extract/faex/extrait de levure, algae extract, caffeine, sodium lauroyl oat amino acids, hydrogenated lecithin, polyethylene, glyceryl stearate, salicylic acid, cholesterol, linoleic acid, acetyl carnitine hcl, glycine, inulin, tromethamine, decarboxy carnosine hcl, phytosphingosine, glycosaminoglycans, cetyl alcohol, tocopheryl acetate, bisabolol, squalane, hdi/trimethylol hexyllactone crosspolymer, behenyl alcohol, carbomer, silica, disodium edta, potassium sorbate, phenoxyethanol, blue 1 (ci 42090), yellow 5 (ci 19140), chromium hydroxide green (ci 77289), titanium dioxide (ci 77891), mica.

Redness Solutions Soothing Cleanser

ingredients: water/aqua/eau, squalane, glycerin, butylene glycol, phenyl trimethicone, ammonium acryloyldimethyltaurate/vp copolymer, avena sativa (oat) kernel extract, cucumis sativus (cucumber) fruit extract, hordeum vulgare (barley) extract/extrait d’orge, sucrose stearate, sea whip extract, cholesterol, helianthus annuus (sunflower) seedcake, chamomilla recutita (matricaria), acetyl glucosamine, ppg-20 methyl glucose ether, caffeine, propylene glycol dicaprate, caprylyl glycol, stearic acid, sodium chloride, disodium edta, bht, phenoxyethanol, polyaminopropyl biguanide, yellow 5 (ci 19140), green 5 (ci 61570), blue 1 (ci 42090).

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One often asked question by newly diagnosed sufferers is `can you get rosacea on areas other than your face’. The usual answer is no; you normally only see rosacea symptoms on the flushing zone areas in the central areas of your face. This paper slightly dispels this idea with a case report about one patient who had rosacea lesions on his arm, and upper chest area.

Rosacea with extensive extrafacial lesions, Int J Dermatol. 2008 Jan;47(1):52-5, Pereira TM, Vieira AP, Basto AS

Rosacea is a very common skin disorder in the clinical practice that primarily affects the convex areas of the face. Extrafacial rosacea lesions have occasionally been described, but extensive involvement is exceptional. In the absence of its typical clinical or histological features, the diagnosis of extrafacial rosacea may be problematic. We describe an unusual case of rosacea with very exuberant extrafacial lesions, when compared with the limited involvement of the face.

The patient had papules, red nodules, pustules and large granulomatous lesions involving the face, neck and upper chest, and extending from the left shoulder along the whole left arm. It was mostly missing from the central facial region. Demodex was not seen as a possibility.

The treatment regime was deflazacort (an oral steroid) 30mg for 3 weeks, azithromycin at 500mg, 3 days a week for 4 weeks and isotretinoin (accutane) 10mg a day for 1 year. The accutane was reduced in the later months. The patient was advised to avoid the sun and use a physical sunscreen (i.e. zinc oxide or titanium dioxide based).

After 1 year, the chest, left shoulder and arm were clear, with some facial redness remaining.

In order to diagnose these symptoms as being rosacea-like, the doctors had to rule out several other possibilities like infectious folliculitis and demodicosis.

Therefore, in this case, the presence clinically of inflammatory papules, pustules, and nodules on a congestive background, with spread from the typical midfacial involvement to other areas of the body, and the presence of poorly organized epithelial granulomas and follicular pustules in the biopsy allow the diagnosis of extrafacial rosacea.

A review of 53 cases of granulomatous rosacea found extrafacial lesions in 15% of the patients.

Interestingly the patient was treated with low-dose accutane and pulse dosing with azithromycin. A 3 week dose of oral steroids was also included.

The paper ends with the following conclusion.

Reports of extrafacial rosacea are rather scarce. However, it may be
more common than it is thought, because it is generally not considered and/or not researched. We presented an unusual setting of extrafacial rosacea that is remarkable for the exuberant and extensive involvement, when comparing with facial involvement, the initial diagnostic difficulty and the good therapeutic results obtained

What about you, have you ever suspected that you have `extrafacial rosacea’ ? How did you treat it ? Leave a comment below.

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A previous study in 2005, Pimecrolimus for treatment of acne rosacea suggested that elidel could indeed be useful for rosacea, but this study was not a double blind study – it was not compared to another inactive topical.

Some preliminary studies suggested that protopic (tacrolimus) may be useful in treating steroid induced rosacea, but again this was not a double blind study. See Tacrolimus ointment for the treatment of steroid-induced rosacea: a preliminary report.

 So here is the abstract for this latest study that is casting doubt on how well elidel can be used to treat rosacea bumps.

Pimecrolimus cream 1% for papulopustular rosacea: a randomized vehicle-controlled double-blind trial.

Br J Dermatol. 2007 Apr;156(4):728-32,Weissenbacher S, Merkl J, Hildebrandt B, Wollenberg A, Braeutigam M, Ring J, Hofmann H

Background: Rosacea remains difficult to treat, despite many therapeutic options. Objectives To investigate the effect of pimecrolimus cream 1% (Elidel((R)); Novartis Pharma, Nuremberg, Germany) in the treatment of papulopustular rosacea.

Methods: Forty patients with rosacea (25 men and 15 women, mean age 58 years) were enrolled in a randomized, vehicle-controlled, double-blind study. For 4-8 weeks, patients applied pimecrolimus cream or vehicle twice daily to the involved areas on the face. Rosacea severity score, subjective severity assessment and quality of life assessment were obtained, along with photographic documentation.

Results: Both treatment groups of 20 patients showed an improvement after 4 weeks. The differences were not significant (P > 0.05) with regard to mean absolute values, mean percentage changes from baseline, or mean absolute values as differences from baseline for the total score or scores of the different clinical signs (erythema, papulation, scaling and pustules). In the subjective severity score and the quality of life assessment, there was also no significant difference between pimecrolimus and the vehicle (P > 0.05).

Conclusions: Treatment of rosacea for 4-8 weeks with the topical calcineurin inhibitor pimecrolimus cream 1% was not more efficacious than treatment with the vehicle cream.

Further Reading:

• seb derm, elidel and protopic : a warning
• over the counter steroids can cause steroid induced rosacea

An interesting exchange in recent editions of the Journal of the American Academy of Dermatology. A paper in July 2005 suggested that the population in general was safely using over the counter hydrocortison (steroids). This conclusion was then challenged by a letter published in Jan 2006 pointing out the abuse of OTC steroids can lead to steroid induced rosacea.

The letter sounds an excellent warning against using even even low-dose corticosteroids ;

This preliminary study demonstrates that tacrolimus 0.075% ointment may be effective for patients with steroid-induced rosacea, when combined with avoidance of topical steroid use, as well as avoidance of other agents known to aggravate rosacea (caffeine, spicy foods, alcohol, hot fluids, and fluoride).

Firstly the original paper

Consumers appropriately self-treat based on labeling for over-the-counter hydrocortisone. Journal of the American Academy of Dermatology, 2005 Jul;53(1):41-51.

Ellis CN, Pillitteri JL, Kyle TK, Ertischek MD, Burton SL, Shiffman S. Department of Dermatology, University of Michigan Medical School, Ann Arbor, Michigan 48109-0314, USA.

BACKGROUND: Over-the-counter (OTC) topical corticosteroids, such as hydrocortisone cream (HC), are commonly used for the treatment of minor dermatological conditions. The safety and efficacy of such products are well documented, but details on patterns of use and self-treatment with HC in the OTC environment remain scarce.

OBJECTIVE: We sought to determine compliance with label directions of OTC HCs by examining self-reported patterns of OTC HC use in adults and children.

METHODS: A random digit-dialed telephone survey was conducted with 2000 US adults. Following identification of users of OTC HC in the last 6 months, respondents were asked questions about the conditions being treated with OTC HC and the frequency and duration of use in both adults and children.

RESULTS: Of adults completing the survey, 20% (n = 396) had used OTC HC. In 83% of cases, the conditions treated were consistent with the OTC label. Use was limited; HC was applied < or =4 times daily in 98% of adult users and lasted < or =7 days in 92%. Patterns of pediatric use were similar and almost always consistent with the labeling. Of households with children, 25% (n = 168) had used OTC HC to treat pediatric dermatological conditions. Of child users, 93% were 2 years of age or older, treatment was limited (97% applied HC < or =4 times daily and 94% of treatments lasted < or =7 days), and the conditions treated were appropriate in 86% of cases.

LIMITATIONS: This telephone survey relied on respondents’ recall and self-reporting. Our data on pediatric use of OTC HC are skewed toward treatment of younger children.

CONCLUSION: The data suggest that OTC HC products are used for self-treatment in a limited and appropriate fashion that is likely to be safe in both adults and children.

Supported by GlaxoSmithKline Consumer Healthcare.Disclosure: Drs Ellis, Pillitteri, and Shiffman and Ms. Ertischek serve as consultants to GlaxoSmithKline Consumer Healthcare; Dr Ellis also serves as a consultant to other manufacturers of topical corticosteroids. Mr. Burton and Mr. Kyle are employed by GlaxoSmithKline Consumer Healthcare.

The follow up letter

Morbidity of over-the-counter topical steroids. (PDF).

Journal of the American Academy of Dermatology, 2006 Jan;54(1):182, Tackett BN, Smith MC, Nedorost ST.

This article emphasizes that over-the-counter usage of hydrocortison is generally safe and appropriate. However, we are greatly concerned with the potential for topical steroid use on facial skin, which may result in steroid-induced rosacea and topical steroid addiction. After observation of long-term facial application of even low-dose corticosteroids, we have see many adults and children with a rosacea diathesis in whom severe burning and itching develop, along with bright red papules and nodules.This may occur after long-term application of even low-potency topical corticosteroids.

Steroid-induced rosace clearly occurs after the use of topical corticosteroid that have never been associated with adrenal suppression.

Application of topical corticosteroids causes immediate vasoconstriction and reduces the redness seen in rosacea and many other skin conditions. However, when patients discontinue usage of the topical corticosteroid, symptoms immediately reappear, and the symptoms are often much worse than those seen in the original condition.

How To Treat Steroid Rosacea

One promising treatment for steroid induced rosacea is tacrolimus. Tacrolimus ointment for the treatment of steroid-induced rosacea: a preliminary report. This preliminary study demonstrates that tacrolimus 0.075% ointment may be effective for patients with steroid-induced rosacea, when combined with avoidance of topical steroid use, as well as avoidance of other agents known to aggravate rosacea (caffeine, spicy foods, alcohol, hot fluids, and fluoride).

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