Steroid rosacea

What is steroid rosacea?

Steroid rosacea is the name given to a rosacea-like condition on the mid-face caused by potent topical steroids or their withdrawal. It is a variant of perioificial dermatitis (also known as perioral dermatitis) or may be the same condition (note that periorificial dermatitis may occur in the absence of topical steroid). It is considered distinct from steroid acne, which is caused by oral corticosteroids.

Who gets steroid rosacea?

Steroid rosacea is most often seen in adult women. However, it can affect males and children.

What are the clinical features of steroid rosacea?

After several weeks of applying a topical steroid to the mid-forehead, eyelids, cheeks or chin, the affected area becomes red.

• Small bumps (papules) and pustules appear. These may be scaly.
• The reddened areas feel burning hot and itchy.
• In time, telangiectasia (enlarged blood vessels) may develop
• The skin becomes sensitive to anything applied to it.

Steroid rosacea may become especially severe when the topical steroid cream is discontinued. This is called a rebound flare.

Steroid induced facial rosacea and perioral dermatitis 

Steroid rosacea 

Steroid rosacea 

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Why do topical steroids cause steroid rosacea?

It is not known why topical steroids cause steroid rosacea. Ideas have included:

• Proliferaton of hair follicle mites, demodex (demodicosis)
• Proliferation of other micro-organisms in the skin
• New blood vessel formation and rebound vasodilation
• Innate immune reaction with inflammatory cytokine release

Steroid rosacea tends to be more likely to occur and more severe when strong steroids have been applied to facial skin. Conversely it is less likely to occur with mild steroids, particularly when applied infrequently. A similar rash has been reported from prolonged application of calcineurin inhibitors (tacrolimus ointment, pimecrolimus cream).

What other effects do topical steroids have on facial skin?

Many adverse effects have been described from the use of topical steroids.

Occasionally steroid rosacea is confused with tinea faciei and tinea incognita (often spelled incognito), fungal infections masked by topical steroids.

Periorificial dermatitis is a less severe steroid-induced rash, in which small papules develop around the lips, around the nose and around the eyelids.

Redness due to steroids 

Steroid telangiectasia 

Tinea faciei treated with topical steroid 

What is the treatment for steroid rosacea?

Steroid rosacea responds well to treatment in most cases, although telangiectasia may persist long-term.

• The topical steroids should be discontinued. To minimise severe flare-up, slow withdrawal is recommended by decreasing how often the topical steroid is applied and choosing another topical steroid that is less potent.
• If moisturisers are used, these should be non-oily.
• Topical pimecrolimus cream may be helpful short-term.
• Oral tetracycline (eg doxycycline) is often prescribed and may be required for several months
• Telangiectasia can be treated with a vascular laser.

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