Systemic Glucocorticoid-Induced Acne
Yes, systemic glucocorticoids definitively induce acne as a recognized adverse effect, occurring through both metabolic and immunologic mechanisms that promote acneiform eruptions. 1, 2
Mechanism of Glucocorticoid-Induced Acne
Systemic glucocorticoids cause acne through multiple pathways that differ from typical acne vulgaris:
Enhanced TLR2 expression: Glucocorticoids (dexamethasone, cortisol) increase Toll-like receptor 2 gene expression in keratinocytes by 2-3 fold, which amplifies inflammatory responses to Propionibacterium acnes present as normal skin flora 3
MAPK pathway modulation: Steroids induce MAPK phosphatase-1, which suppresses p38 MAPK activity, paradoxically increasing TLR2 expression and creating a pro-inflammatory environment despite the anti-inflammatory properties of glucocorticoids themselves 3
Metabolic effects: Glucocorticoids produce papulo-pustular acne as a direct metabolic complication, distinct from the comedonal pattern of typical acne 2, 4
Clinical Presentation
The acne induced by systemic glucocorticoids has characteristic features:
Morphology: Predominantly papulo-pustular lesions rather than comedones 1, 2
Distribution: Can occur on face, chest, and back similar to acne vulgaris but may have more uniform appearance 2
Timing: Develops during systemic glucocorticoid therapy, with severity correlating to dose and duration of treatment 2, 4
Evidence from Clinical Guidelines
Multiple authoritative sources document this adverse effect:
EULAR rheumatology guidelines (2007) list acne as a recognized adverse event of systemic prednisolone, methylprednisolone, and deflazacort alongside hyperglycemia, hirsutism, and osteoporosis 1
ISHAM-ABPA guidelines (2024) specifically identify acne as an adverse event of systemic glucocorticoids used for allergic bronchopulmonary aspergillosis treatment 1
Dermatology literature confirms that both systemic and topical glucocorticoid administration provokes acneiform reactions clinically, despite their anti-inflammatory properties 3
Dose and Duration Relationship
The risk of glucocorticoid-induced acne increases with:
Higher doses: More severe side effects occur with higher glucocorticoid dosages 2, 4
Longer duration: Prolonged treatment courses carry greater risk for cutaneous complications including acne 2, 5
Individual susceptibility: Patients with pre-existing acne or those prone to acneiform eruptions may be at higher risk 3
Clinical Management Considerations
When prescribing systemic glucocorticoids, clinicians should:
Anticipate acne development as a predictable adverse effect, particularly in adolescents and young adults who may already have acne-prone skin 2, 4
Use minimum effective doses and shortest treatment duration necessary to minimize metabolic side effects including acne 1
Avoid treating steroid-induced acne with additional systemic steroids, as this represents a contraindication—low-dose prednisone (5-15 mg daily) is discouraged as primary acne therapy due to long-term adverse effects 1
Consider topical acne treatments (retinoids, benzoyl peroxide) or other acne-specific therapies rather than adjusting steroid dosing if acne becomes problematic 1
Important Caveat
The paradox of glucocorticoid-induced acne is noteworthy: while systemic steroids have anti-inflammatory properties that theoretically should improve acne, they simultaneously upregulate inflammatory pathways (TLR2) and cause metabolic changes that promote acneiform eruptions 3. This explains why low-dose prednisone is specifically discouraged for acne treatment despite its anti-inflammatory effects 1.