Friday, May 21, 2010

Facial erythema Secondary to Topical Corticosteroids

Abstract:  37 yo man with marked facial erythema who has been using hydrocortisone valerate 0.2% cream (HC valerate) for 20 years.

HPI:  HC valerate was prescribed for a facial eruption when the patient was a teenager.  He's been using it ever since.  Over time, he has developed marked painful facial erythema.

O/E:  There is fiery erythema over the malar eminences, periorbital areas and portions of forehead.  Three weeks after stopping the HC valerate, using cool compresses b.i.d. and minocycline 100 mg b.i.d. the process persists.

Clinical Photo: May 20, 2010 (three weeks after stopping HC valerate

Diagnosis:  Red Face Syndrome.  Facial addiction to topical corticosteroid.

Questions:  Other than abstinence and cold compresses, are there any other treatments you have had success with?  What about topical tacrolimus ointment?

Reference:  The most helpful reference I have found is:
Papaport MJ, Rapaport V. Eyelid dermatitis to red face syndrome to cure: clinical experience in 100 cases.  J Am Acad Dermatol. 1999 Sep;41(3 Pt 1):435-42.
A retrospective review of all eyelid dermatitis patients seen over an 18-year period revealed a large subgroup of patients who had, as the basis for their ongoing problem, an addiction to the use of topical or systemic corticosteroids. This group of 100 patients often sought many consultations with various physicians. Unrelenting eyelid or facial dermatitis often resulted in the use of increasing amounts of corticosteroids for longer periods of time. Soon the skin became addicted. Once the work-up ruled out other causes, the remedy for the problem was absolute total cessation of corticosteroid usage. This article describes the typical history of the problem, the evaluation of these patients, and the distinctive pattern of flaring erythema that ensued when the corticosteroids were ceased. We stress the absolute necessity of total cessation of corticosteroid use as the only treatment for corticosteroid addiction. We also demonstrate that no additional therapy or further consultations were necessary once remission was obtained after topical corticosteroid abuse was halted.

This may be worth a trial:
Goldman D. Tacrolimus ointment for the treatment of steroid-induced rosacea: a preliminary report.  J Am Acad Dermatol. 2001 Jun;44(6):995-8
BACKGROUND: Excessive topical corticosteroid application to facial areas commonly leads to steroid-induced rosacea. This may be a recalcitrant problem that requires months of antibiotic and anti-inflammatory therapy before it resolves. OBJECTIVE: The purpose of this article is to review the use of tacrolimus ointment, a macrolide anti-inflammatory ointment for the treatment of 3 patients with steroid-induced rosacea. METHODS: Three patients with steroid-induced rosacea applied tacrolimus ointment, 0.075% twice daily for 7 to 10 days. Patients were also instructed to avoid topical corticosteroid use and other rosacea-aggravating substances including caffeine, spicy foods, alcohol, hot fluids, and fluoride. Patients were observed for tenderness, erythema, and relief of pruritus. RESULTS: Pruritus, tenderness, and erythema were resolved in all 3 patients after 7 to 10 consecutive days' use of tacrolimus 0.075% ointment in conjunction with avoidance of topical steroids, caffeine, spicy food, alcohol, hot fluids, and fluoride. CONCLUSION: 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).


  1. Ashok Kumar SharmaMay 21, 2010

    I have seen quite a number of cases with skin abused by topical corticosteroids. The cutaneous manifestations have varied from predominant erythema (telangiectasia)only to florid rosacea-like picture with papules.Now there are 2 concerns here. One is why the patient started using the steroid in the first place; was it a steroid responsive dermatosis? Most of the times it has been difficult for me to arrive at an answer by clinical examination; the history suggests some kind of an itchy rash probably dermatitis (may have been photosensitive or not). The other issue is to advise and to make sure the patient stops using the steroid immediately; this is also not easy. Although I tend to prescribe tacrolimus/pimecrolimus for my patients along with emollients and a sunblock, however follow-ups have shown that the patient reverts to the steroid when he/she feels unsatisfied by my new line of management either because of initial aggravation of erythema or initial aggravation of pruritus or because of the patient's preconceived notions. Patients who do stick to not using the steroids do feel better after about 2-3 months; telangiectasia doesn't go completely. For a couple of my patients I tried Pulsed Dye Laser for persistent telangiectasia but response was not satisfactory for the patient and also objectively.
    One concern haunts me whenever I see such a case. Should they be weaned off steroids immediately or gradually, as their skin has been 'addicted' to topical steroids very commonly for years? I do it immediately however for my patients.

  2. AnonymousMay 21, 2010

    Steroid facial erythema is one of the major skin problem among iraqi young patients especially females.They usually use topical clobetasole(dermovate)to the face in order to become more white or for treatment of melasma.Over time they will change into steroid addict which is very difficult to manage.I usually stop steroid gradually using diluted steroid together using very mild soap and sometime I give antirosacea therapy.If we stop steroid immediatly ,the patient will have florid picture of dermatitis that need steroid.
    khalifa sharquie

  3. this is a common concern when u recomend topical steroids on face in india.apparently there are certain over the counter(otc) steroidal products available in india which are being used as a normal face cream patient keeps on using this product for years together and lands to you with features of rosacea .(topical steroid addiction) i prefer using topical calcineurin inhibitors rather than using a weaker steroid, with anti rosacea medications , H1 blockers and sunblock .

  4. AnonymousMay 22, 2010

    It is Steroid induced rosacea. I prefer TIMs (Pimecrolimus more than tacrolimus) with oral Cap isotretinoin 5 to 10 mg/ day; sunscreens and moisturisers.
    Weaning such apatient from steroids is a big ask. A lot of these patients take months to improve.
    Regular follow ups with intermittent courses of Azithromycin may be needed.
    Dr Manish Pahwa
    New Delhi,

  5. HORRIBLE problem. He will revcover but it will take probably over a year. Protopic usually helps a lot. Hopefully, he doesn;t have glaucoma?? that is the biggest problem. from Fran Storrs, Portland Oregon

  6. I am going through topical steroid withdrawal and into 7th week, not to the face except eyelids, but primarily arms, neck, and sides of torso. Clearly the red skin syndrome Dr. Rapaport references. I attempted to taper off over summer, and as he notes in his manuscripts, it doesn't work. You indeed must stop all treatments.

    Can you please follow up on this patient's condition now and post? I would love to know how he is doing.

  7. Could we have an update as to how this man is doing now? I am also going though steroid withdrawal and have been off the creams for 6 months after stopping cold turkey in December. Things are slowly improving for me. My blog is at

  8. Patient Follow-up -- May 2012: The patient is almost completely clear and being maintained with tacrolimus 0.03% ointment two times a week. He will wean himself off that. Louise UK's comments are important and can be found on her web site given above.

  9. Hi, I was wondering whether any rebound occurred when the patient was trying to wean himself off tacrolimus 0.03%.


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