The role of dermoscopy in a topical steroid-damaged face

A 29-year old male presented with pinkish-red erythema over the cheeks with patchy brown discoloration and grossly visible telangiectasias of 6 months’ duration (Figure 1). He also complained about his facial skin being very sensitive, especially to sun exposure. The patient was aware that he had melasma and gave a history of occasional use of sunscreen in the past. Despite repeated and persuasive questioning, he staunchly denied applying any topical steroid-containing formulations or depigmenting creams. Polarized dermoscopic examination (EScope; Nakoda, ×20) of the cheeks revealed a reddish-brown background, brown dots, globules and clods, multiple tortuous and branching linear vessels and telangiectasias, and ivory white-to-strawberry ice cream colored patches in addition to conspicuous hypertrichosis (Figure 2A–2B). Suspecting topical steroid abuse, he was shown the dermoscopic features on the computer screen and cautioned about the complications of “topical steroid-damaged face.” He finally admitted to having used a mometasone-containing triple combination cream over the cheeks twice a day for the previous 4 months, at the suggestion of a friend. Since his last examination, the patient has been using a broad-spectrum sunscreen on a daily basis, topical vitamin 20% serum and has been scheduled for intense pulsed light therapy for facial rejuvenation.

Figure 1.

Clinical picture of the patient showing pinkish-red erythema over the cheeks with patchy brown discoloration and grossly visible telangiectasias. [Copyright: ©2018 Sonthalia et al.]

Figure 2.

(A, B) Dermoscopy of the cheek revealing reddish-brown background, brown dots, globules and clods (black arrows) suggestive of a background of melasma, multiple tortuous and branching linear vessels (white arrows), telangiectasias and ivory white-to-strawberry-colored patches (blue arrow) suggestive of skin atrophy, in addition to conspicuous hypertrichosis (Escope, videodermoscope, polarizing mode, 20×). [Copyright: ©2018 Sonthalia et al.]

Prominent telangiectasias, ivory white-to-strawberry-colored patches (suggestive of skin atrophy) and lesional hypertrichosis constitute dermoscopic features which are indicative of “topical steroid-damaged face,” while the brown pigmented structures suggest a background of melasma. The abuse of topical steroid-containing formulations over the face has now been well established as a dermatological nuisance in India [1].

Conclusions

Through this report, we wish to highlight that many of these patients are in a denial about their steroid abuse. Importantly, dermoscopy not only noninvasively confirms the suspicion, but also aids in the patient’s understanding of the seriousness of topical steroid abuse through the demonstration of pictures explained in patient-friendly language. In the majority of cases it also ensures further steroid abuse and improves treatment compliance [2].