Saturday, September 03, 2016

The Tortured Tube

The patient is a 25 yo man with a 4 mo hx of an eyelid dermatitis.  His mother, a health professional, gave him 0.1% triamcinalone oinment to apply ~ 2 months ago.  It has run out and he came in for an appointment.  He is healthy and has a history of atopic dermatitis that is now quiescent.
Diagnosis and Discussion: I think this is an example of "steroid acne."  It's hard to tell what preceded it.  Most topical corticosteroids when applied for weeks or more to thin skin such as is seen on the face (expecially eyelids or around the mouth) or the genitalia can cause this.  It's a type of steroid addiction.

The standard treatment is to stop the topical steroid, apply cold compresses two time a day and doxycycline 100 mg b.i.d. for a month or more.  The longer this has been going on, the harder it is to treat.

Reference:  Dr. Ken Fowler and I reported a similar patient in 2001.
Tortured tube" sign. Fowler KP, Elpern DJ.  West J Med. 2001 Jun;174(6):383-4. Free FullText Online.


  1. Yoon Cohen wrote: "It is so tough to treat, and probably he will want to continue to apply even after learning the truth about potent steroid..
    Would you consider Protopic or Elidel?"

  2. What kind of "health professional" is the patient's mother?

    She gave him "1% triamcinolone ointment"--where did she get this? It is supplied as 0.1%, not 1%. What was she treating?

    Whatever the dose, it is too strong to use around the eye and ointments act even stronger than creams since they are occlusive.

    Non-physicians often use an inappropriate strength of topical steroid and may not specify how long to use it.

    This is a big issue as more nurses and PAs work as physicians without a physician license and have little experience in skin diseases, but frequently use the highest strength of topical steroid in the erroneous notion that the strongest is the best for any skin disease. These are ideas I have gotten from some of these "prescribers" I have spoken to.

    I am not sure how these experiences will inform the new world of health care which is supposed to improve quality of care and efficiency.

    As for treatment, many of these patients will say that they cannot stop the strong steroid. I have them use 1% or 2.5% hydrocorticone cream in place of the stronger drug and will give them a few days of low-dose prednisone if not contraindicated along with encouragement that they are not addicted to the original cream. Cool compresses for a few minutes will help pruritis. The patient may need some hand-holding to get them through.

    1. Are you worried about rebound with such a short course of prednisone?


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