# Steroid-induced skin atrophy

Steroid-induced skin atrophy is thinning of the skin as a result of prolonged exposure to topical steroids. This is the most common side effect of overuse or misuse of topical steroids. Topical steroids are typically prescribed for psoriasis, atopic dermatitis (eczema), and other itchy rashes. In people with psoriasis using topical steroids it occurs in up to 5% of people after a year of use. Intermittent use of topical steroids for atopic dermatitis is safe and does not cause skin thinning.
Skin atrophy can occur with both prescription and over the counter steroids creams. Strength of the topical steroid will influence its propensity to cause skin atrophy. Oral prednisone and intralesional steroids may also result in skin atrophy.

## Signs and symptoms

Skin atrophy typically presents as thin, shiny skin. Once it develops, further topical steroid side effects may occur, such as telangiectasia, easy bruising, purpura, and striae. Application of topical steroids to intertriginous areas such as the armpits, under the breasts, or on the groin, use of occlusive dressings and fluorinated steroids all increase the likelihood of developing atrophy.

## Prevention

In general, use a potent preparation short term and weaker preparation for maintenance between flare-ups. While there is no proven best benefit-to-risk ratio, if prolonged use of a topical steroid on a skin surface is required, a pulse therapy should be undertaken.
Pulse therapy refers to the application of a corticosteroid for 2 or 3 consecutive days each week or two. This is useful for maintaining control of chronic diseases. Generally a milder topical steroid or non-steroid treatment is used on the in-between days.
For treating atopic dermatitis, newer (second generation) corticosteroids, such as fluticasone propionate and mometasone furoate, are more effective and safer than older ones. They are also generally safe and do not cause skin thinning when used in intermittently to treat atopic dermatitis flare-ups. They are also safe when used twice a week for preventing flares (also known as weekend treatment). Applying once daily is enough as it is as effective as twice or more daily application.
Strong steroids should be avoided on sensitive sites such as the face, groin and armpits. Application of weak steroids to these areas should be limited to less than two weeks of continuous use.

## Topical Steroid Classes

Topical steroids are divided into classes based on potency. Low potency steroids (hydrocortisone, triamcinolone acetonide) may be used on any surface of the body and for a longer period (typically 1-2 weeks). Higher potency steroids (clobetasol, betamethasone) are reserved for severe pruritus that has been refractory to lower potency topical steroids. Higher potency steroids are used for a shorter periods to control exacerbations.

## Treatment

The obvious priority is immediate discontinuation of any further topical corticosteroid use. Protection and support of the impaired skin barrier is another priority. Eliminating harsh skin regimens or products will be necessary to minimize potential for further purpura or trauma, skin sensitivity, and potential infection. Steroid-induced skin atrophy is often permanent, though if caught soon enough and the topical corticosteroid discontinued in time, the degree of damage may be arrested or slightly improve. However, while the accompanying telangiectasias may improve marginally, the stretch marks are permanent and irreversible.