Clinical and epidemiological study of topical steroid abuse in Nepal: an observational study from a tertiary hospital

Abuse of topical corticosteroids is an emerging problem. Irrational and non-judicious use of steroids can cause disastrous effects, the awareness of which is essential.

Abstract

Background

Abuse of topical corticosteroids is an emerging problem. The irrational and nonjudicious use of steroids can cause disastrous cutaneous and systemic adverse effects.

Objectives

To study the clinical and epidemiological profile of topical steroid abuse.

Methods

A total of 124 patients who were misusing topical steroids were included in this hospital-based observational study. Details of the patients, indications of topical corticosteroid use and adverse cutaneous effects were recorded in a proforma and analysed.

Results

The majority of patients (n = 52; 41.9%) were aged between 21 and 30 years. A female predominance (n = 75; 60.5%) was recorded. Students formed the largest subgroup of the study population. The major indication for topical steroid abuse was dermatophytic infection (n = 52; 41.9%). The face was the most common site of topical steroid application (n = 68; 54.8%). Ultrapotent steroids were commonly used (n = 55; 44.4%). The majority of patients applied topical steroid once daily (n = 91; 73.4%). Topical steroid use was predominantly advised by a pharmacy (n = 70; 56.5%). Erythema was the common adverse effect observed (n = 59; 47.6%).

Conclusions

This study highlights the pattern and epidemiological profile of topical corticosteroid misuse. Thus, policymakers should raise awareness of this issue and introduce laws for regulation.

What is already known?

• Topical steroid abuse is a widespread issue.

• Irrational use of topical steroid can cause disastrous adverse effects.

What does this study add?

• The study highlights the prevalence, demographics, patterns and consequences of topical steroid misuse among patients.

• The study emphasizes the need for awareness, regulation and education to prevent misuse and improve dermatological care.

Topical corticosteroids are among the most widely prescribed medications in dermatology for various dermatological conditions. Drug misuse is defined as the use of a substance for purpose not consistent with legal or medical guidelines.¹ Topical steroid use is a double-edged sword. Judicious use of topical steroid requires knowledge and understanding, as steroids are beneficial in treating inflammatory, hyperproliferative and pruritic dermatoses. However, the irrational use of topical steroids can be disastrous and can lead to adverse cutaneous effects, which depend on the pattern and potency of steroid use.² Steroid-induced dermatoses include atrophy, telangiectasias, acneiform eruptions, rosacea, perioral dermatitis, purpura, aggravation of infections, striae, contact dermatitis, tachyphylaxis and corticosteroid withdrawal patterns.³ Factors contributing to steroid misuse include lack of awareness, easy availability without prescription, self-medication, advertisements, poor drug policy and regulation, and decreased health-seeking behaviour among the general population.⁴ There is a lack of studies on topical steroid misuse in Nepal. Hence, this study was conducted to assess the pattern of abuse of topical steroids, reinforcing their rational use through education, legal and ethical approaches.

Patients and methods

A hospital-based descriptive exploratory cross-sectional study was conducted on patients of all ages and both sexes visiting the Outpatient Department of Dermatology of Civil Service Hospital, Nepal, for 1 year from 4 February 2023 to 10 February 2024. Steroid abuse was defined as self-use of over-the-counter topical corticosteroids for inappropriate indications and where their use actually contraindicated, or the use of an inappropriate potency of topical steroid or the use of a topical steroid for more than 1 month. Patients were prospectively selected if they (i) brought a sample of the steroid they had used; (ii) used topical steroids for dermatological conditions where steroids are contraindicated, or used an inappropriate potency of steroid, or used the steroid for an inappropriate length of time; and (iii) presented with at least one adverse effect of topical steroid misuse as the chief complaint.

Patients with comorbidities that might cause similar changes (Cushing syndrome, thyroid disorders, polycystic ovaries), patients using combined topical preparations and patients in whom the use of topical corticosteroids could not be confirmed were excluded from the study.

The minimum sample size was calculated to be 47 on the basis of the prevalence rate of steroid misuse of 3.2% reported in a previous study.⁵ All patients who visited the dermatology outpatient department of the Civil Service Hospital from 4 February 2023 to 10 February 2024, were evaluated for steroid misuse, and 124 patients were included in the study via the convenience sampling technique.

A detailed medical was taken, and a thorough clinical examination was performed in all patients after obtaining written informed consent. The content of the topical application used was confirmed by the investigator. A detailed history of topical corticosteroid use, including potency, duration, frequency, prescription source and adverse effects, was evaluated. Patient photographs were taken. Data recorded in a proforma were entered and analysed with SPSS version 20 (IBM, Armonk, NY, USA).

Results

The mean (SD) age of the patients in our study was 31.3 (12.3) years (range 5–81). Most patients (n = 52/124; 41.9%) were aged between 21 and 30 years (Figure 1). A female predominance (n = 75/124; 60.5%) was observed with a female : male ratio of 1.53 : 1. The majority (n = 64/124; 51.6%) of patients belonged to lower middle-class families, and 42 (33.9%) had attained a higher secondary level of education. Students formed the largest subgroup in our study (Figure 2). The majority of participants used topical steroids for dermatophytic infection (n = 52/124; 41.9%), followed by melasma (n = 46/124; 37.1%) and eczema (n = 8/124; 6.5%) (Table 1). Among dermatophytes, topical steroids were predominantly used for tinea corporis (n = 21/52; 40%). The median duration of steroid usage was 3 months (range 15 days–10 years). Face (n = 68/124; 54.8%), followed by trunk (n = 23/124; 18.5%) and groin (n = 18/124; 14.5%) were the most common sites of application of topical steroid (Figure 3). Ultrapotent class I (n = 55/124; 44.4%) and potent class II (n = 53/124; 42.7%) steroids were commonly used by participants (Figure 4). The majority of participants applied topical steroids once daily (n = 91/124; 73.4%) and on alternate days (n = 18/124; 14.5%) (Figure 5). Our study revealed that topical steroid use was predominantly advised by a pharmacy (n = 70/124; 56.5%) or by friends (n = 29/124; 23.4%) (Figure 6). Erythema (n = 59/124; 47.6%) was the most common adverse effect observed with steroid misuse in our study, followed by burning (n = 48/124; 38.7%) and itching (n = 35/124; 28.2%) (Table 2), and are depicted in Figures 7–10.

Figure 1.

Age group (years) distribution of the study population.

Figure 2.

Occupational distribution of the study population.

Table 1.

Indications for topical steroid misuse in the study cohort (n = 124)

Indication	n (%)
Tinea	52 (41.9)
Melasma	46 (37.1)
Eczema	8 (6.5)
Acne vulgaris	5 (4.0)
Candidal balantis	2 (1.6)
Pigmentary disorder	3 (2.4)
Pruritus	4 (3.2)
Lichen planus	1 (0.8)
Rosacea	1 (0.8)
Seborrhoeic dermatitis	1 (0.8)
Seborrhoea	1 (0.8)

Figure 3.

Site of topical steroid application in the study participants.

Figure 4.

Potency of topical steroid used by the study participants.

Figure 5.

Frequency of topical steroid use in the study participants.

Figure 6.

Sources of recommendation to use topical steroids in the study population.

Table 2.

Adverse effects of topical steroid misuse in the study participants (n = 124)

Adverse effects	n (%)
Erythema	59 (47.6)
Burning	48 (38.7)
Itching	35 (28.2)
Stinging	33 (26.6)
Photosensitivity	29 (23.4)
Acne	21 (16.9)
Hypertrichosis	21 (16.9)
Atrophy	20 (16.1)
Perioral eczema	5 (4.0)
Flushing	2 (1.6)
Aggravation of old lesion	1 (0.8)

Figure 7.

Facial erythema in the malar region with steroid abuse.

Figure 10.

Steroid-induced rosacea.

Figure 8.

Telangiectasias and atrophy on the medial aspect of the foot.

Figure 9.

Striae on the thigh.

Discussion

Topical corticosteroids are the most commonly prescribed drugs by dermatologists because they play a substantial role in managing various dermatoses; however, they are widely misused. Steroid misuse is frequently associated with adverse cutaneous manifestations, requiring awareness among the public and enforcement of drug dispensing laws.

The prevalence of steroid misuse has been reported to range from 3.2% to 9%.^5–7 In our study, of 17 000 patients, 124 (0.7%) had a history of topical steroid abuse, which is lower than that reported in earlier studies. This could be attributed to decreased health-seeking behaviour among individuals with skin complaints.

The mean age of the patients in our study was 31.3 years, which is comparable to that reported in a study by Prabhu et al.⁸ In our study, the age range of participants was 5–81 years, which is similar to findings from earlier studies.⁸ Most of the patients in our study were aged between 21 and 30 years, which is consistent with earlier studies.^9,10 Individuals in this age group are more likely to seek treatment for dermatological concerns and are exposed to wide range of treatment modalities.

A female predominance was observed, with a female : male ratio of 1.53 : 1, which is similar to the findings of a study by Rohit et al.¹⁰ Misuse was found to be higher in female patients in two studies carried out in India, primarily due to the intention of achieving a lighter complexion.^11,12 Students composed the majority of the population in our study, which is similar to the findings of a study by Swaroop et al.;¹¹ however Parajuli et al.¹³ found that steroid misuse is common in homemakers. Easy access to over-the-counter topical steroids, peer pressure and social media influence could be the reasons for the steroid misuse in students.

The majority of patients used topical steroids for dermatophytic infection, followed by melasma, which is consistent with studies reported in the literature.^5,8,10 In studies conducted by Dey and Hameed, the most common indication for steroid misuse was to achieve lighter skin.^14,15 With regard to dermatophytic infections, steroids were predominantly used for tinea corporis, while Prabhu et al. observed steroid misuse in patients with tinea cruris.⁸

The median duration of steroid use was 3 months, with a range of 2 weeks to 10 years, which is consistent with a study conducted by Parajuli et al.;¹³ however, a study conducted by Rathi et al. reported that the duration of steroid abuse ranged from 4 months to 20 years.¹⁶ Topical steroids result in transient improvement of different dermatoses and show rebound effects when stopped, which might be the reason for the use of topical steroids intermittently for long durations.¹⁷

The face was the most common site of topical steroid application, which is in accordance with a study conducted by Saraswat et al.¹⁷ This might be due to cosmetically appreciable effects, and the use of steroids as skin-lightening agents.¹⁸ The most common site of application in a study by Rohit et al. was the thigh, which might be due to a large number of dermatophytic infections noted in that study.¹⁰

Ultrapotent (class I) steroids were commonly used by our patients, which is consistent with previous studies.^5,8,10 This is in contrast to findings reported by Parajuli et al., who documented class IV steroid to be the most often abused.¹³ The difference can be explained by the availability of topical steroids and better transient response with the use of potent steroids.

Topical steroids were predominantly advised by pharmacists, which is in accordance with previous studies and can be explained by the easy availability of drugs at chemist shops without the need for a prescription.⁵ Topical corticosteroids fall under the category of Schedule H drugs, which should be sold only with a prescription from a registered doctor; however, this is not readily practised in Nepal.¹⁹ Some studies report unlicensed practitioners, friends and family members to be mainly responsible for the provision of topical corticosteroids to others.^8–13

In our study, the most common adverse effect due to steroid abuse was erythema, which is consistent with the observations of Parajuli et al.¹³ Erythema secondary to topical steroid use occurs due to the release of nitric oxide from dermal endothelial cells, causing vasodilation.^3,13 Acneiform eruption and tinea incognito have been reported in other studies to be the major cutaneous side effects.^{5,9–12,18,20} This difference can be due to pre-existing dermatoses, potency and patterns of steroid use. Although prolonged use of potent topical corticosteroid can cause systemic effects, these effects were not observed in our study.

Topical steroid misuse has emerged as a significant dermatological and public health issue in Nepal. Addressing steroid misuse in the general population requires a multifaceted approach. Widespread education and awareness campaigns about the dangers of unsupervised topical steroid use, strict regulation and enforcement of prescription-only sales implemented by concerned authorities can reduce steroid misuse, prevent complications and promote healthier skin practices in the community. As our study was based in a single centre, it might not represent the true clinical scenario, suggesting a need for multicentre studies with a large sample.

The unsupervised use of topical steroids is increasing rampantly in Nepal. Our study highlights the epidemiological profile and the pattern of topical corticosteroid misuse in our community. Thus, policymakers should raise awareness and introduce drug regulation laws to prevent steroid abuse.

Author contributions

Prajwal Pudasaini (Conceptualization [lead], Data curation [lead], Methodology [lead], Writing—original draft [equal], Writing—review & editing [equal]), Sagar GC (Conceptualization [lead], Methodology [lead], Writing—original draft [equal], Writing—review & editing [equal]), Sushil Paudel (Conceptualization [lead], Methodology [lead], Writing—original draft [equal], Writing—review & editing [equal]), Ranjeet Yadav (Data curation [lead], Formal analysis [lead], Supervision [equal], Writing—original draft [equal]), Mauricio Salas-Garza (Conceptualization [lead], Formal analysis [equal], Methodology [lead], Writing—original draft [equal]), Shekhar KC (Conceptualization [lead], Data curation [lead], Methodology [equal], Writing—original draft [equal]), Sadiksha Adhikari (Conceptualization [lead], Data curation [lead], Methodology [equal], Writing—review & editing [equal]) and Sunil Jaiswal (Formal analysis [lead], Methodology [lead], Supervision [lead], Writing—original draft [lead], Writing—review & editing [equal])

Conflicts of interest

The authors declare no conflicts of interest.

Funding sources

None declared.

Data availability

The data underlying this article will be shared on reasonable request to the corresponding author.

Ethics statement

Ethics approval was granted by the Institutional Review Committee of Civil Service Hospital, Nepal.

Patient consent

Patients provided written informed consent.