Corticosteroids Are Contraindicated in Acne Patients

Ronni Wolf, MD, Edith Orion, MD, Hagit Matz, MD

Disclosures

Skinmed. 2003;2(1) 

Introduction

It is written: both systemic and topical corticosteroids can exacerbate or precipitate acne or even induce an acneform eruption. Corticosteroids are considered to be acnegenic comedogenic drugs, and it would make good sense to make every effort to avoid using them in patients with current acne or a tendency to develop it. In a word, corticosteroids are essentially contraindicated in acne-prone patients.[1,2,3,4] This caveat is pertinent today more than ever since the advent of organ and bone marrow transplantation and the introduction of aggressive oncologic treatment regimens that have made corticosteroid acne a more common condition.[5,6]

Not so.

We treat all our patients who suffer from inflammatory acne with systemic corticosteroids by having them follow a regimen of prednisone 20-30 mg/day for a period of 2-4 weeks. After decades of cumulative experience with countless patients, we can testify that no other medications can compete with corticosteroids for giving immediate improvement of this condition. We believe that patients who need systemic treatment with either antimicrobials or retinoids should initially be put on concomitant short-term treatment with corticosteroids as well. This therapeutic protocol also prevents the flare-up of acne so often seen at the beginning of isotretinoin therapy.

We are not alone in trying to dispel the myth. Several acne experts have previously suggested the use of physiologic dosages of prednisone (5-7.5 mg), with or without estrogens, to lower androgen levels and reduce sebaceous glands activity.[7,8,9,10] We are not aware of any others who advocate the use of corticosteroids in effective anti-inflammatory dosages such as the ones we use except in severe acne cystica and conglobata with systemic reactions or acne fulminans.[11,12] Indeed, investigators[13] failed to achieve improvement in patients with moderate acne using a potent topical steroid cream. On the other hand, an interesting Japanese report[14] described a patient with malignant lymphoma who acquired steroid-withdrawal rosacea-like dermatitis: the condition returned each time the patient interrupted oral prednisone therapy.

We would be the last to deny that the currently available nonsteroid medications are effective. None of them, however, acts within days or even weeks; systemic corticosteroids at a medium dosage (20-40 mg/day) provide an immediate reduction in clinical signs. A rapid result is not to be scoffed at: not only does it make the patient look and feel good (and there's nothing wrong in scoring major points for being a clever physician), it enhances patient compliance, a major cause of treatment failure. When we are dealing with aesthetics, we are talking about a positive impact on the patients' self-esteem and well being, quite often when they sorely need to see encouraging therapeutic progress. Finally, the possible prevention of permanent unsightly scarring needs no elaboration.

Use your clinical judgment, not a popular myth, to select the patients with acne for whom steroids are contraindicated. Use steroids for the rest of them without compunction.

(Top) A 40-year-old woman who suffered a flare of acne after withdrawal of contraception. (Bottom) The same woman 2 weeks after treatment with 30 mg/day systemic prednisone (image enhanced for clarity)

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