Topical corticosteroids (TCS) are among the most commonly prescribed therapeutic agents in dermatology and have remained a cornerstone in the management of inflammatory skin disorders since the introduction of hydrocortisone (compound F) in 19521. Their widespread utility stems from their potent anti-inflammatory, vasoconstrictive, antiproliferative, antipruritic, melanopenic, immunosuppressive, and hormone-like effects on the skin2. These pharmacological properties allow TCS to offer rapid symptomatic relief in a broad range of dermatological conditions, including eczema, psoriasis, and dermatitis, making them invaluable for both short- and long-term treatments. However, despite their effectiveness, the indiscriminate or prolonged use of TCS—especially high-potency formulations—can lead to an array of adverse effects, many of which are more severe and frequent when these agents are used improperly3. Typically, side effects begin to manifest after three to four weeks of continuous daily application and are often reversible upon cessation. Nonetheless, improper or extended use, particularly on sensitive areas such as the face, can lead to distinctive and often distressing dermatological reactions. Adverse facial effects include steroid rosacea, acneiform eruptions, hypertrichosis, and demodicidosis. These conditions are further complicated by syndromes such as steroid addiction dermatitis, rosaceaformis steroidica, red face syndrome, and what has recently been described as topical steroid-dependent face (TSDF)4,5. In TSDF, patients develop severe rebound erythema, burning, and scaling of the facial skin upon discontinuation of TCS, signifying a physical and psychological dependency on these agents. This condition highlights the potential dangers of chronic steroid use on facial skin and the challenge of managing withdrawal symptoms. The misuse of TCS is not merely a clinical issue but a public health concern, especially in countries like India6. The Indian pharmaceutical market offers at least 18 different corticosteroid molecules ranging in potency from mild to super-potent. These drugs are marketed under thousands of brand names and are readily available at most retail pharmacies, often without the need for a medical prescription7. This easy accessibility, compounded by lax enforcement of drug regulation laws, has created an environment conducive to self-medication and misuse. The situation is exacerbated by a severe shortage of trained dermatologists in India—fewer than 7,000 professionals serve a population exceeding 1.4 billion8,9. As a result, individuals often resort to over-the-counter use of TCS, frequently driven by non-medical advice or cosmetic concerns, particularly for conditions such as facial pigmentation, acne, or generalized itching. Social media, unverified online sources, and beauty influencers also contribute to the misinformation about these potent drugs, promoting their use for quick skin lightening or blemish removal10,11. These practices often result in worsened skin conditions, resistance to standard therapies, and increased cases of steroid-induced dermatoses. The problem of TCS misuse is not confined to India. Several studies from Africa and other Asian nations have documented similar patterns of inappropriate corticosteroid use. In these regions, socioeconomic factors, lack of healthcare access, and limited public awareness contribute to the rampant misuse of TCS12. Interestingly, even developed countries like the United States are not immune to this issue. In the U.S., although regulations are stricter and dermatological care more accessible, there are still reported cases of corticosteroid misuse, often related to overuse13, patient non-compliance with tapering regimens, or misunderstanding of medical instructions. However, the scale and systemic impact of TCS misuse are especially pronounced in India. Despite the perceived magnitude of the problem, there remains a paucity of scientific literature addressing this issue in the Indian context, with only a single case series published to date14. This lack of robust data hampers the formulation of effective policy responses and public health strategies15-17.

AIM

To evaluate the misuse of topical corticosteroid on face in patients attending tertiary care hospital.

The study was conducted in the outpatient clinic of Dermatology Government medical College Sri Ganganagar .Individuals of all ages and both sexes were recruited. Patient details were systematically recorded using a pre-designed questionnaire, which included information on age, social status, type of topical corticosteroid (TCS) used, source of prescription, indication for use and any observed adverse effects. The study particularly focused on identifying and categorizing the clinical side effects associated with TCS misuse on the face. These included conditions such as steroid-dependent face (SDF), defined as rebound flares of itching, redness, pustulation, and scaling following cessation of treatment, which often leads to continued dependency on TCS. Another commonly observed entity was steroid-induced rosacea, characterized by persistent facial erythema, telangiectasia, papulonodular lesions, and scaling over the affected areas.

Table 1: Age presentation of our study

The age distribution of the participants shows that 4 were aged 0–10 years, 15  were 11–20 years, 22 were 21–30 years, 8 were 31–40 years, and 1 was 41–50 years.

Table 2: Area of residence

Out of the total participants, 18 (36%) were from urban areas and 32 (64%) were from rural areas.

Table 3: Composition, Potency, and Number of Patients Using Topical Corticosteroids

The most frequently used topical corticosteroid preparation was Betamethasone valerate 0.1% (Class III) used by 15 patients, followed by various combinations including Betamethasone with Neomycin, Gentamycin, Clioquinol, Tolnaftate, and Miconazole (mostly Class III), Mometasone with Hydroquinone and Tretinoin (Class IV), and Clobetasol-based formulations (Class I), with usage ranging from 11 to 1 patient.

Table 4: Source of Topical Corticosteroid Acquisition

The sources of the drug among patients included relatives (15), practitioners of alternative systems of medicine (11), neighbours (8), friends (7), pharmacists (5), non-dermatologists (3), and dermatologists (1).

Table 5: Indications for Use of Topical Corticosteroids on the Face

The indications for using topical corticosteroids among patients included acne (22), melasma (13), tinea (6), general face cream use (4), fairness cream (3), and undiagnosed conditions (2).

Table 6: Side effects encountered in our study

The reported side effects included aceniform eruption in 25 patients, pruritus in 18, photosensitivity in 16, erythema in 9, seborrheic dermatitis facies in 7, hyperpigmentation in 6, while no cases of striae or xerosis were observed.

The majority of patients were in the 21–30 years (22 patients, 44%), followed by those aged 11–20 age group (15 patients, 30%). Younger children aged 0–10 years accounted for 4 cases (8%), while 8 patients (16%) were between 31–40 years, and only 1 patient (2%) was in the 41–50 age group.In a study by MR Swaroop 201918 this shows that topical corticosteroid use was most prevalent among adolescents and young adults. Out of 100 patients, the most common age group was 21-30yrs (35%).

Out of the total patients, 18(36%) were from urban areas, while 32 (64%) belonged to rural regions. This indicates a higher prevalence of topical corticosteroid use in rural populations. The urban–rural difference may reflect easier access to over-the-counter products in rural areas.In a study done by Asha Nyati 201719 When the number of patients using these two groups were compared against their area of residence, it was found that potent steroids were significantly more frequently used in the rural and suburban areas compared with the urban areas (p=0.0445)

The most commonly used formulation was Betamethasone valerate 0.1% (Class III), used by 15 patients. This was followed by Betamethasone valerate 0.1% with Neomycin sulphate 0.5% (Class III) in 11 patients and Mometasone furoate 0.1% with Hydroquinone 2% and Tretinoin 0.025% (Class IV) in 8 patients. Six patients used Betamethasone valerate 0.1% with Gentamycin, Tolnaftate, and Clioquinol (Class III), while 4 used Clobetasol propionate 0.05% with Gentamycin and Miconazole nitrate (Class I). Other combinations included Betamethasone with Gentamycin and Miconazole nitrate (3 patients), Betamethasone with Clioquinol (2 patients), and Clobetasol propionate 0.05% alone (1 patient).In a study done by AK JHA 201620 A total of 410 patients were observed One hundred and seventy-eight patients (43.4%) used topical steroids alone, 124 (30.2%) used creams containing TC, hydroquinone, and tretinoin, 108 (26.3%) used creams containing a combination of TC, antibiotic, and/or antifungal.

The most common source of the drug was relatives, accounting for 15 patients (30%), followed by practitioners of alternative systems of medicine in 11 patients (22%). Neighbours contributed to 8 cases (16%), while friends were the source for 7 patients (14%). Pharmacists provided the drug to 5 patients (10%), and non-dermatologists to 3 patients (6%). Only 1 patient (2%) obtained the drug through a dermatologist.In a study done by A saraswat et al 201121 non-physician recommendation for TC use was obtainable in 257 (59.3%) patients. Of these, 232 (90.3%) were for potent/super-potent steroids. Among 176 physician prescriptions, 78 (44.3%) were from non-dermatologists. All non-physician prescriptions and 146 (83%) physician prescriptions for TC were inappropriately refilled.

The most common indication for topical corticosteroid use was acne, reported by 22 patients (44%), followed by melasma in 13 patients (26%). Tinea was the reason for use in 6 patients (12%), while 4 patients (8%) used it as a general face cream. Three patients (6%) used it as a fairness cream. Additionally, 2 patients (4%) used it without a specific diagnosis. In a study by S. Fasih 202022 Multiple adverse effects like erythema, burning, itching, telangiectasia, hypertrichosis, tinea incognito, photosensitivity and skin atrophy were noted. Among those who developed side effects, 98 (44.5%) patients developed Topical Steroid Dependent Face (TSDF).

The most common side effect observed was aceniform eruption in 25 patients (50%), followed by pruritus in 18 (36%) and photosensitivity in 15 (30%). Erythema was seen in 9 patients (18%), seborrheic dermatitis facies in 7 (14%), and hyperpigmentation in 6 (12%). Notably, no cases of striae or xerosis were reported. These findings highlight the dermatological complications associated with topical corticosteroid misuse. In the study by Jha et al. (2016)20, the most commonly reported side effects of topical corticosteroid misuse included aceniform eruption and seborrheic dermatitis facies (SDF), each observed in 9% of cases. Rosacea and hypertrichosis were also reported in 8% and 9% of patients, respectively. Other side effects included pruritus (4%), erythema (2%), telangiectasia (3%), perioral dermatitis (1%), infections (1%), hypopigmentation (1%), and atrophy (1%). Hyperpigmentation, photosensitivity, striae, xerosis, and wrinkles were not specifically mentioned in the study. In a study by M Thomas 202023 Almost 58% of participants perceived their skin conditions to be allergic reactions to food, when in fact 70.1% were tinea, 10% scabies and 9% acne. Eighty per cent of the respondents having tinea had tinea incognito and 97% had extensive lesions. Eighty-five per cent of the participants with scabies had atypical lesions and 80% with acne had steroid rosacea or aggravation of acne.

Topical corticosteroid (TCS) misuse on the face has become a significant issue for both patients and dermatologists, particularly in India. Many individuals use TCS as general face creams or fairness creams due to easy over-the-counter availability and weak regulatory control. This widespread and injudicious usage has led to a rise in facial complications commonly seen in clinical practice. The lack of awareness among the general public and healthcare providers further aggravates the problem. To combat this growing epidemic, strict regulatory laws and proper education for both patients and medical professionals are urgently needed.

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