The hidden steroid problem in fairness and mixed creams

Key takeaways

• Topical steroids are useful prescription medicines for eczema and some rashes, used at the right strength for a limited time. The problem is misuse.
• In India, steroid creams are widely used for fairness, acne, fungal infections and undiagnosed rashes, often on a chemist's or a friend's advice, and mixed combination creams are common.
• Strong steroids on the face for weeks to months can cause thinning, visible blood vessels, redness and burning, steroid rosacea, acne-like bumps, extra facial hair and a rebound flare when stopped.
• Steroid combination creams for ringworm make fungal infections spread and look atypical, which makes them harder to treat.
• Since March 2018, a number of topical steroids have been under Schedule H, meaning they should only be sold on prescription.

What exactly is the problem?

See, what happens is, a steroid cream switches off inflammation quickly. Redness goes, itching stops, and in the first few weeks the skin may even look lighter and smoother, because strong steroids reduce pigment and blood flow at the surface. People feel the cream "works". So they keep using it, or recommend it to a cousin.

Over weeks and months, the same steroid thins the skin. DermNet lists the effects of prolonged use of potent steroids: skin thinning (atrophy), visible small blood vessels (telangiectasia), increased hair growth, a rash around the mouth and nose (periorificial dermatitis), steroid rosacea, and fungal infection that is masked or made worse. It also lists withdrawal symptoms. When the person stops, the redness and burning come back stronger. So they restart. That is dependence, and it is very common in my clinic.

That is very important to understand: the cream did not fail. It did exactly what a strong steroid does, on skin that was never meant to have it.

How common is this in India?

More common than most people imagine. A commentary in the Journal of Pharmacology and Pharmacotherapeutics noted that topical steroids made up about 82 percent of dermatological product sales in India in 2013, and raised concern about their use for acne, bacterial and fungal infections, undiagnosed rashes and as fairness creams, often by unregistered practitioners or on chemist advice. It also noted that fixed-dose combinations of steroids with antibacterial and antifungal agents were widely available, and that two such combinations were among the top-selling steroid formulations.

A study in BMJ Open among new dermatology outpatients in rural Uttarakhand found that 29 percent had misused topical steroids. Clobetasol propionate, a very potent steroid, was the most common. About 70 different combination creams were collected from patients. Pharmacists were the largest single source. Among those who used steroids for acne, 58 percent developed steroid rosacea or worse acne.

Indian dermatologists have also linked steroid combination creams to the outbreak of widespread, hard-to-treat ringworm in recent years.

Which creams contain steroids?

Steroid creams are not always labelled as "steroid". Read the ingredient list on the tube or box for these names, and others ending in "-sone", "-solone" or "-lone":

DermNet notes that very potent steroids can be up to 600 times as strong as hydrocortisone. Be especially careful with: - "Ringworm" or "itch" combination creams that contain a steroid plus an antifungal and an antibiotic, sometimes four ingredients in one tube. - Pigmentation creams that combine hydroquinone, tretinoin and a steroid. These triple combinations do have a place in treating melasma for a limited period under a doctor's supervision, but used for months or years they can cause the same steroid damage. - Fairness or "herbal" creams from unknown sources. In 2017, the Indian Association of Dermatologists, Venereologists and Leprologists filed a public interest petition in the Delhi High Court over steroid-containing creams marketed for fairness, pigmentation and itching, including some presented as herbal.

If the label is unclear, take the tube to a doctor.

What does the law say now?

In March 2018, a government notification placed 14 topical steroids under Schedule H of the Drugs and Cosmetics Rules, so they should be sold only on a doctor's prescription. This was a step forward. In practice, enforcement varies, and many people still buy them across the counter or have old tubes at home. The rule protects you only if you know what to ask for and what to refuse.

What does steroid damage on the face look like?

Patients often come to me with: - A red, hot, burning face that flares in the sun or with heat, especially on the cheeks. - Fine visible veins on the cheeks and nose. - Small red bumps and pimples around the mouth, nose and chin. - Thin, shiny skin that bruises or stings easily. - New fine hair on the cheeks or forehead. - Patchy skin colour: lighter where the cream went, darker around it. - Ringworm that keeps spreading in rings, with an unusual look, after using a combination cream.

Normally, people blame their skin, the weather or their diet. The tube in their handbag is the answer.

How do I stop a steroid cream safely?

Please do not stop a long-used potent steroid on your own and suffer through the flare without support. And please do not switch to another mixed cream. Here is what I do with my patients:

1. Confirm what you have been using. Bring every tube and box.
2. Make a plan to stop. For some, we stop at once. For others, especially after long use of a very potent steroid, we step down to a milder one for a short period, then stop.
3. Calm the skin. A gentle cleanser, a plain fragrance-free moisturiser and a mineral sunscreen. Nothing else. See sensitive skin.
4. Treat the flare. A doctor may prescribe non-steroid anti-inflammatory creams or tablets for steroid rosacea or acne. These are prescription decisions after assessment.
5. Treat any fungal infection properly with the right antifungal, for the right duration.
6. Treat pigmentation last, once the skin is calm, with sun protection and gentle creams. See dark marks after pimples and uneven skin tone.

Recovery takes time, often weeks to months. The thinning and redness improve for many people, though visible blood vessels may need laser later. I would rather you know this upfront.

When is a steroid cream the right choice?

Basically, when a doctor has diagnosed a condition that needs it, such as eczema or contact dermatitis, prescribed the weakest strength that will do the job, and told you how long to use it. DermNet's advice is to use the weakest effective steroid, avoid potent steroids on thin skin such as the face, eyelids and skin folds, and use them for a limited time. Used like that, steroids are safe and helpful medicines. The trouble starts when they are bought for the wrong reason and used without an end date.

How we approach this at Dr Tvacha

I see steroid-damaged skin often in Thane and Mumbai, and I never judge anyone for it. Most people were simply told the cream would help. At a Rs 499 skin consultation I check the tubes, look at the skin and write down a plan to stop safely, calm the skin and then treat what was there originally. Any treatment is quoted in writing before you pay. The approach is on the Second Layer Skin Plan page, and our centres are in Thane, Andheri, Bandra and Dahisar.

Written by

Dr Amit KarkhanisAesthetic Physician · MBBS, Dip. Dermatology (UK) · Reg. No. 2001/02/1124

Founder of Dr Tvacha, practising in Thane since 2005. Leads the weight loss and hair programmes.