Arijit Coondoo

Topical Corticosteroid Misuse: The Indian Scenario

Topical corticosteroids (TC) have been available for more than six decades during which they have completely changed the face of therapy of dermatological disorders. Despite being the most useful drug for such treatment they are known to produce serious local, systemic and psychological side-effects when overused or misused. Though the drug has been misused sporadically earlier, the menace has become more acute during the last two decades. In India, damaging effects to the human body particularly the skin have been reported regularly during the last decade. The misuse occurs at various levels such as manufacturing, marketing, prescription, sales and end-use by patients and laymen. During the last decade dermatologists in India have been regularly campaigning against such misuse. However, the menace keeps on increasing alarmingly. The need to accelerate the momentum of the campaign against TC misuse has been increasingly felt by dermatologists all over India. This symposium aims to contribute significantly to the campaign against misuse of TC.

Topical corticosteroid addiction and phobia

Corticosteroids, one of the most widely prescribed topical drugs, have been used for about six decades till date. However, rampant misuse and abuse down the years has given the drug a bad name. Topical steroid abuse may lead to two major problems which lie at the opposing ends of the psychosomatic spectrum. Topical steroid addiction, a phenomenon that came to be recognized about a decade after the introduction of the molecule is manifested as psychological distress and rebound phenomenon on stoppage of the drug. The rebound phenomenon, which can affect various parts of the body particularly the face and the genitalia has been reported by various names in the literature. TC phobia which lies at the opposite end of the psychiatric spectrum of steroid abuse has been reported particularly among parents of atopic children. Management of both conditions is difficult and frustrating. Psychological counseling and support can be of immense help in both the conditions.

Topical steroid damaged/dependent face (TSDF): An entity of cutaneous pharmacodependence

Topical Steroid Damaged/Dependent face (TSDF) is a phenomenon which has been described very recently (2008). It is characterized by a plethora of symptoms caused by an usually unsupervised misuse/abuse/overuse of topical corticosteroid of any potency on the face over an unspecified and/or prolonged period of time. This misuse and damage have a serious effect on the quality of life of the patients in general and the skin of the face in particular. Management is difficult and necessitates psychological counseling as well as physical soothing of the sensitive skin.

Lichen Planus Pigmentosus: The Controversial Consensus.

A pigmented variant of lichen planus (LP) was first reported from India in 1974 by Bhutani et al. who coined the term LP pigmentosus (LPP) to give a descriptive nomenclature to it. LP has a number of variants, one of which is LPP. This disease has also later been reported from the Middle East, Latin America, Korea, and Japan, especially in people with darker skin. It has an insidious onset. Initially, small, black or brown macules appear on sun-exposed areas. They later merge to form large hyperpigmented patches. The disease principally affects the sun-exposed areas of the body such as the face, trunk, and upper extremities. The oral mucosa may rarely be involved. However, the palms, soles, and nails are not affected. Histologically, the epidermis is atrophic along with vacuolar degeneration of basal cell layer. The dermis exhibits incontinence of pigment with scattered melanophages and a sparse follicular or perivascular infiltrate. There is a considerable similarity in histopathological findings between LPP and erythema dyschromicum perstans. However, there are immunologic and clinical differences between the two. These observations have led to a controversy regarding the identity of the two entities. While some dermatologists consider them to be the same, others have opined that the two should be considered as distinctly different diseases. A number of associations such as hepatitis C virus infection, frontal fibrosing alopecia, acrokeratosis of Bazex and nephrotic syndrome have been reported with LPP. A rare variant, LPP inversus, with similar clinical and histopathological findings was reported in 2001. As opposed to LPP, this variant occurs in covered intertriginous locations such as groins and axillae and mostly affects white-skinned persons.

Use and abuse of topical corticosteroids in children

Topical corticosteroids (TC) have been in use for more than half a century and are useful for the treatment of various inflammatory disorders in all age groups including children. Children, however, form a special age group because their skin, being more thin and tender, is more susceptible to the side-effects of the drug. Hence dermatologists must be aware of this special situation where TC must be prescribed with utmost caution. Counselling of parents and others handling the children is also imperative for judicious use of the drug. Planned withdrawal of the drug as early as possible helps in avoiding tachyphylaxis and most of the side-effects of the drug.

Serendipity and its role in dermatology.

Serendipity is a pleasant surprise of finding a particularly useful information while not looking for it. Significant historic events occurring as a result of serendipity include the discovery of the law of buoyancy (Archimedes principle) by the Greek mathematician Archimedes, of the Americas by Christopher Columbus and of gravity by Sir Isaac Newton. The role of serendipity in science has been immensely beneficial to mankind. A host of important discoveries in medical science owe their origin to serendipity of which perhaps the most famous is the story of Sir Alexander Fleming and his discovery of Penicillin. In the field of dermatology, serendipity has been responsible for major developments in the therapy of psoriasis, hair disorders, aesthetic dermatology and dermatosurgery. Besides these many other therapeutic modalities in dermatology were born as a result of such happy accidents.

Tender skin nodules in a newborn

Subcutaneous fat necrosis of infancy is a rare disorder of subcutaneous adipose tissue that is sometimes complicated by hypercalcemia. Complete resolution is common. From the pediatricians point of view, the disease is a rare but important cause of inconsolable cry in a newborn.

Drug interactions in dermatology: What the dermatologist should know

A drug interaction is a process by which a drug or any other substance interacts with another drug and affects its activity by increasing or decreasing its effect, causing a side effect or producing a new effect unrelated to the effect of either. Interactions may be of various types-drug-drug interactions, drug-food interactions, drug-medical condition interactions, or drug-herb interactions. Interactions may occur by single or multiple mechanisms. They may occur in vivo or in vitro (pharmaceutical reactions). In vivo interactions may be further subdivided into pharmacodynamic or pharmacokinetic reactions. Topical drug interactions which may be agonistic or antagonistic may occur between two drugs applied topically or between a topical and a systemic drug. Topical drug-food interaction (for example, grape fruit juice and cyclosporine) and drug-disease interactions (for example, topical corticosteroid and aloe vera) may also occur. It is important for the dermatologist to be aware of such interactions to avoid complications of therapy in day-to-day practice.

Single lesion of sarcoidosis presenting as cicatricial alopecia: a rare report from India.

Sarcoidosis affects different systems of the body including the skin where it can affect various cutaneous sites. Among these sites, the scalp is a very unusual location for lesions of sarcoidosis. Sarcoidosis of the scalp can very rarely be accompanied by cicatricial alopecia. We report here a rare case of sarcoidosis of scalp with cicatricial alopecia. To the best of our knowledge, this is the first such report from India.

Topical corticophobia among parents and caregivers of atopic children

Topical corticosteroids are one of the most frequently prescribed medications for skin diseases especially for atopic dermatitis (AD). Due to the rampant over-the-counter availability of these medications, misuse, and abuse of these drugs is well documented. The undesirable side-effects of corticosteroids are often seen in these patients. This has recently given rise to the phenomenon of“topical steroid phobia” where the patients or their caregivers are reluctant to use them even when prescribed by the physicians. This makes the proper management of steroid-responsive diseases like AD, very difficult. In this article, we have discussed the causes of emergence of this phobia, the problems it is posing and how to deal with them.