Can Steroid Injections Cause Acne?
Yes, steroid injections can cause acne—this is a recognized adverse effect explicitly listed in the American Academy of Dermatology guidelines for intralesional corticosteroid use in acne treatment. 1
Mechanism and Clinical Context
Steroid acne is a documented adverse effect of corticosteroid administration, whether given systemically (oral, intravenous) or via intralesional injection. 1 The American Academy of Dermatology's 2016 guidelines specifically list "steroid acne" as one of the adverse effects/toxicities of intralesional triamcinolone acetonide injections used to treat inflammatory nodulocystic acne. 1
Key Clinical Features
Steroid-induced acne differs from acne vulgaris in several important ways:
- Onset timing: Steroid acne can develop acutely, sometimes within days of corticosteroid administration, particularly with intravenous formulations. 2
- Morphology: Presents as uniform monomorphic papules and pustules, rather than the mixed comedonal and inflammatory lesions of acne vulgaris. 3
- Distribution: Often affects the upper trunk and shoulders more prominently. 4
- Resolution: Typically resolves spontaneously after withdrawal of the steroid without scar formation, unlike acne vulgaris. 3
Risk Factors and Incidence
The incidence varies by route of administration:
- Intralesional injections carry risk as a listed adverse effect in prescribing guidelines. 1
- Intravenous corticosteroids showed a 2% incidence in one prospective study of hospitalized patients. 2
- Systemic oral steroids commonly cause steroid acne, though the exact incidence varies. 1, 3
Important caveat: Over 80% of patients with acneiform eruptions while receiving systemic steroids actually have Pityrosporum folliculitis (fungal folliculitis caused by Pityrosporum ovale), not true steroid acne. 4 This distinction is critical because the treatments differ fundamentally.
Management Approach
If acneiform eruption develops after steroid injection:
- Consider Pityrosporum folliculitis first if lesions are discrete follicular papules/pustules on the upper trunk. 4
- Perform direct microscopy to identify Pityrosporum ovale organisms. 4
- Trial oral antifungal therapy (itraconazole) if Pityrosporum is suspected or confirmed, as this shows superior efficacy compared to traditional anti-acne medications in steroid-associated eruptions. 4
- Discontinue or reduce steroid dose when medically feasible, as steroid acne typically resolves spontaneously after withdrawal. 3
Additional Adverse Effects to Monitor
Beyond acne, intralesional corticosteroid injections can cause:
- Local atrophy, pigmentary changes, and telangiectasias from overdose. 1
- Hypertrichosis (increased hair growth). 1
- Sterile abscess formation. 1
- Hypothalamic-pituitary-adrenal axis suppression with repeated injections. 1
Common systemic steroid side effects include blurred vision, insomnia, hypertension, increased appetite, weight gain, hyperglycemia, and mood changes. 1