What is the treatment for steroid-induced acne?

Treatment of Steroid-Induced Acne

For steroid-induced acne, the recommended first-line treatment is a combination of topical retinoid with benzoyl peroxide, which addresses both the inflammatory and comedonal components of the condition. 1

Understanding Steroid-Induced Acne

Steroid-induced acne differs from typical acne vulgaris in several ways:

• It typically appears after systemic or topical corticosteroid administration
• It often resolves without scarring after discontinuation of the steroid 2
• It may have a more monomorphic presentation with predominantly inflammatory papules and pustules

Treatment Algorithm

First-Line Treatment

1. Topical Combination Therapy

   • Fixed-dose combination of topical retinoid with benzoyl peroxide 1
   • This combination provides both anti-inflammatory and comedolytic effects

2. Topical Antibiotics (if needed)

   • Clindamycin 2%, erythromycin 1%, or metronidazole 0.75% 1
   • Always use in combination with benzoyl peroxide to prevent antibiotic resistance 1
   • For isolated scattered lesions: cream formulation
   • For multiple scattered areas: lotion formulation

For Moderate to Severe Cases

1. Oral Antibiotics

   • Doxycycline (100 mg twice daily) is the first choice 1
   • Minocycline (100 mg twice daily) as an alternative 1
   • Always use with topical benzoyl peroxide to prevent antibiotic resistance 1
   • Minimum treatment duration of 2 weeks 1

2. Short-term Topical Steroids (for inflammatory component)

   • Prednicarbate cream 0.02% for short-term use 1
   • Apply only to inflammatory areas
   • Discontinue as soon as inflammation subsides

For Severe or Recalcitrant Cases

1. Consider Isotretinoin

   • For severe cases not responding to conventional therapy 1
   • Starting dose: 0.5 mg/kg/day for the first month
   • May increase to 1.0 mg/kg/day as tolerated
   • Target cumulative dose: 120-150 mg/kg 1
   • For moderate cases: lower doses (0.25-0.4 mg/kg/day) may be effective 1

2. For Female Patients

   • Consider combined oral contraceptive pills 1
   • Alternative: spironolactone (particularly effective for hormonal component) 1

Special Considerations

Pityrosporum Folliculitis Overlap

• In some cases, steroid acne may have significant Pityrosporum ovale (Malassezia) involvement 3
• Consider antifungal treatment if:
  • Lesions are predominantly on upper trunk
  • Patient has multiple acneiform lesions on both face and body
  • Standard treatments are ineffective
• Oral itraconazole has shown significant efficacy in these cases 3

Acne Fulminans

If steroid-induced acne progresses to acne fulminans (rare):

• Oral prednisolone 0.5-1 mg/kg daily for 4-6 weeks with slow taper 4
• Add oral isotretinoin at week 4, starting at 0.5 mg/kg daily and gradually increasing 4

Monitoring and Follow-up

• Reassess after 2 weeks of treatment 1
• If no improvement or worsening occurs, escalate to next level of therapy
• For severe cases, consider referral to a dermatologist 1

Important Caveats

• Avoid using topical antibiotics as monotherapy due to risk of bacterial resistance 1
• Limit systemic antibiotics when possible to reduce development of antibiotic resistance 1
• For patients on isotretinoin, pregnancy prevention is mandatory for those with childbearing potential 1
• Consider discontinuation of the causative steroid if medically feasible