Steroid acne and rebound phenomenon

Journal of Drugs in Dermatology, June, 2008 by Steven L. Harlan

Abstract

Background: There have been many reports of topical steroids treatment for the face causing perioral dermatitis, steroid acne, and steroid rebound phenomenon.

Objective: To assess patient reported outcomes in patients receiving compounded topical (hydrocortisone 0.75% and precipitated sulfur 0.5%) lotion for up to 15 years for common dermatological conditions of the face.

Methods: In a retrospective study, 300 patients were randomly sampled from the dermatology clinic who had used, or were continuing to use, a lotion based, pharmacy-compounded topical preparation for the face. The topical compound was used in therapies for seborrheic dermatitis and combination with prescription topical therapy for patients with acne and rosacea with tolerability problems.

Results: None of the 300 patients experienced steroid acne, rebound phenomenon, or perioral dermatitis associated with . use of hydrocortisone 0.75% and precipitated sulfur 0.5% on the face.

Conclusion: There was no evidence found that perioral dermatitis, steroid acne, or rebound phenomenon occurs when sulfur is compounded with topical hydrocortisone 0.75%.

Introduction

With the many reports of naked steroids on the face causing perioral dermatitis and steroid acne, a perception exists that topical steroids cannot be used on the face, under any circumstances, due to concerns of rebound phenomenon, steroid acne, and perioral dermatitis. Dermatology training may emphasize these concerns, and may not provide exposure to successful treatments of compounding steroids with sulfur or steroids with topical antibiotics.

Steroid addiction occurs when patients overuse steroids on the face, groin, or the genitalia to the point of erythema and burning symptoms. These symptoms quickly worsen when the steroid is withdrawn, demonstrating a rebound phenomenon. Steroid acne most often occurs when naked corticosteroids are used on the face for an extended period of time. Steroid acne may also occur when systemic steroids are used in a susceptible person. This has also been observed in patients using large amounts of topical steroids on the extremities for psoriasis, who develop steroid acne on the face and back from systemic absorption.

However, there is evidence that when topical steroids, particularly low potency steroids, are used on the face in combination with an antimicrobial agent, rebound phenomenon and steroid acne does not occur, and in 1976, an insightful study supported this idea.1 In that study of 19 subjects with rosacea, facial topical steroids were given in conjunction with oral tetracycline for rosacea, which did not cause rebound phenomenon when the steroids were discontinued.

The present retrospective review of 300 patients (57 with rosacea) provides evidence that when low potency topical steroids are used in combination with an antimicrobial agent (ie, precipitated sulfur), rebound phenomenon for steroid acne does not occur, even after prolonged use.

Topical precipitated sulfur has acquired "grandfather status" in dermatologic therapy. The pure element sulfur is not related to a sulfa allergy. A sulfa allergy is an immunologic reaction to an organic benzene ring moiety. Sulfur is mined from a vein and processed to remove impurities. After pharmaceutical grade purity is reached, the result is available as a dry yellow powder called precipitated sulfur. The pure element sulfur is a reducing agent and has antimicrobial properties2 and a 5% concentration has keratolytic effects on the skin.

Precipitated sulfur has been used for Demodex folliculitis and rosacea for a century. Dermatologists have often plucked Demodex from the follicles of patients using a sticky substance and then mounted the specimens on the microscope slide for quantification. There was a clear relationship that many flares of rosacea were related to a proliferation of Demodex in the skin. Forton et al (3) reported a concentration of less than 1 Demodexj[cm.sup.2] in healthy skin and 30 to 60/[cm.sup.2] in flared rosacea patients.

When treating rosacea patients, it was demonstrated that sulfur reduced the quantity of Demodex. Sulfur was toxic to the Demodex, possibly by inhibiting the bacteria in the gut of the Demodex that are essential for digesting keratin and sebum.

Compounds of precipitated sulfur 5% have been used in acne and rosacea regimens, and were the treatment of choice in pregnant and lactating mothers with scabies.4 Since the 1950s, many dermatologists have compounded steroids with precipitated sulfur for treating psoriasis on the extremities. It was believed that sulfur compounded with steroids helped reduce folliculitis from topical psoriasis therapy on hairy skin. Interestingly, sulfur tends to treat the microbial problems that cannot be cultured. (Coincidentally, it is these same microbial problems that seem to lack the due attention in clinical discourse.)

Material and Methods

The patient medical histories from a dermatology practice were randomly sampled and included in the chart review and follow-up interviews based on 3 criteria: (1) the patients had not previously used topical steroids on the face; (2) patients used the pharmacy compounded hydrocortisone 0.75% and precipitated sulfur 0.5% in a lotion base on the face with the problems of either mixed seborrheic dermatitis/helioder-matitis, rosacea, acne with tolerability problems, or perioral dermatitis; and (3) patients had returned for follow-up at least twice, and had been seen for follow-up within the past year.