Steroid Acne

Steroid acne is an acneiform eruption of uniform inflammatory papules and pustules that follows systemic, inhaled or topical corticosteroids, or anabolic and androgenic steroids. It resembles acne vulgaris but is more monomorphic and has few or no comedones.

It appears within 2 to 6 weeks of starting treatment, and affects the trunk, upper arms and face most often. Risk is highest with high doses and prolonged courses, and in adolescents and young adults.

It occurs in people on oral prednisolone, in recipients of inhaled steroids via a face mask, in people using potent topical steroids on the face, and in athletes using anabolic steroids. Cushing syndrome produces a similar eruption.

Pathophysiology.

Corticosteroids and androgens increase sebaceous gland activity and follicular inflammation. They may also promote a Malassezia overgrowth and alter the follicular epithelium, which leads to a monomorphic papulopustular response.

• Sudden crop of uniform erythematous papules and pustules, without comedones, on the chest, back, shoulders and upper arms, sometimes the face.
• Mild itch or soreness, occasionally severe in Malassezia overgrowth.
• Healing without scars in most patients, though nodular lesions can scar.
• Features of corticosteroid excess (moon face, striae, bruising) in some.

• Clinical diagnosis from the timing relative to steroid exposure and the monomorphic pattern.
• Skin scraping or swab for Malassezia (potassium hydroxide microscopy) and bacterial culture when pustules persist.
• Review for Cushing syndrome if there is no steroid exposure, and a drug and supplement history including anabolic steroids.

Differential diagnosis. Malassezia folliculitis, acne vulgaris, bacterial folliculitis, rosacea (including topical steroid induced rosacea), perioral dermatitis, eosinophilic folliculitis and drug induced acne.

• Stop or reduce the steroid when this is safe. Never stop long term systemic corticosteroids suddenly because of adrenal suppression. Use steroid sparing treatment of the underlying disease when appropriate.
• Topical benzoyl peroxide 2.5 to 5% once daily, and a topical retinoid (adapalene 0.1% or tretinoin 0.025%) at night.
• Oral doxycycline 100 mg daily for 8 to 12 weeks for moderate or extensive disease. If Malassezia folliculitis is present, add ketoconazole 2% shampoo as a body wash for 5 minutes before rinsing, once daily for 5 days then weekly, or itraconazole 200 mg daily for 7 days.
• Isotretinoin 0.5 mg/kg/day for resistant or scarring disease. Women of childbearing potential need reliable contraception and monthly pregnancy tests.
• Stop anabolic steroids, and counsel on risks.

Monitoring. Review at 4 to 8 weeks. Monitor adrenal function and bone health in people on long term systemic steroids.

Referral and escalation. Refer to dermatology if disease is severe, scarring, or fails to respond.

Special groups. Avoid tetracyclines, isotretinoin and topical retinoids in pregnancy. Use azelaic acid 15% gel twice daily as an alternative.