Introduction

TSDF is defined as the temporary or permanent damage to the skin of the face aggravated by the unreasonable, nonselective, unsupervised, or long- term use of TCs resulting in a plethora of cutaneous signs and symptoms and psychological dependence on the drug.^[1] Facial epidermis is comparatively thinner as compared to the rest of the body which results in increased percutaneous absorption of drugs. Also, face has a profuse blood supply which increases incidence of side effects. ^[2] The functionality of the most widely used topical therapeutic agent by dermatologists, has become a double-edged sword with increasing prevalence of misuse, leading to catastrophic consequences. ^[1]

Materials and Methods

This was a cross-sectional, questionnaire-based study, conducted from July 2021 to December 2021, at the outpatient Department of Dermatology, Venereology & Leprosy, of a tertiary care hospital, North East India. The participants had given their consent to participate in the study before filling out the questionnaire. The questionnaire included the demographic data of the participants (age, gender, nationality, place of residence, marital status, education, and employment status). Then, it was followed by questions about the usage of TCs- detailed clinical history of steroid application, source of prescription, reason of misuse and the presenting side effects. It was followed by detailed examination for side effects of TS like acne, erythema, telangiectasia, dyspigmentation, hypertrichosis etc.

Results & Observations

Out of 300 patients who misused topical steroids, majority were females (72%). Maximum patients were in the age group 26-35 years. The most common brand used was Betnovate C which contained betamethasone (0.1% w/w) & clioquinol (3%w/w). The average duration of use was less than 6 months (51%), shortest being 15 days and longest being 4 years. The most common reason for misuse was acne (38%) followed by fairness (22%) & the most common effect observed after misuse was also acne form eruptions (25%) followed by erythema (17%). Most of the users had attained education till primary school. Abuse was commonly from purchase of the drug OTC or from pharmacists.

OTC supply of topical steroid creams mainly by the pharmacist (41%) remains the leading cause for unsupervised application of steroid on face in our study.

Out of 300 patients used TCS on face for Acne.[Figure 1]

153 patients applied steroid on face less than 6 months & 69 patients applied for more than 1 year, maximum duration being 4 years in our study.

Most common adverse effect noted were steroid induced acne in 25% of patients (75 in number).

T.incognito was found in only 5% patients (15 in number)

Discussion

In India, the first case series on topical corticosteroid abuse was published in the year 2006. Thereafter, many authors have tried to focus on the jeopardy caused by its misuse.^[2] As the easy availability and accessibility of topical corticosteroids with various combination offers rapid symptomatic relief so its overuse is common. This was described more than 30 years ago as “serious” in a classic paper by Kligman and Frosch. ^[3]

In this study, maximum number of patients belonged to the age group of 26-35 years which is in concordance with the study done by Nyati A et al^[4] and Saraswat et al. ^[5]

Most of our patients had received educational qualification less than primary school.^[6]

Out of 300 patients enrolled in our study, 216 (72%) were females and 84(28%) were males. Our study was in accordance with other national and international studies. ^[2], ^[7], ^[8]

The most common prescription source for steroid application was from OTC by the recommendations by the chemist in 41% of patients in our study. And most commonly abused topical steroid was betamethasone & clioquinol combination cream. similar to studies done in India by Saraswat A et al., Bornali Dutta et at. ^[5], ^[8], ^[9]

Duration of application of steroid cream was less than 6 months in our study and most of the other studies as well.^[4], ^[8]

The most common cause of steroid application in our study was due to acne (38%) and most common adverse effect noted post application of steroid was also acne form eruptions. (25%) as seen in other studies.^[4], ^[10]

Conclusion

Topical steroids of different potency are very widely and easily available in almost every pharmacy of India. Such an easy access to this drug has increased abuse to a great extent leading to many local, systemic as well as psychological side effects. The situation is further worsened due to lack of proper legislations and laws regarding selling of steroid formulations over the counter. In this study, we had tried to discover the awareness among the patients, the demographic pattern, and also common side effects of TC use in the face. ^[11]

Recommendations

All healthcare providers need to be sensitized about the dangers of topical corticosteroid misuse, especially on the face. Stronger implementation of existing laws is required to limit public access and advertising of TC in any form.

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Abbreviations

TS: Topical Steroid; TSDF: Topical Steroid Damaged Face; OTC: Over The Counter.

Conflict of Interest

None.

Source of Funding

None.