How should I manage acne induced by systemic steroid therapy, especially if the steroid cannot be discontinued?

Management of Steroid-Induced Acne

For acne induced by systemic steroids that cannot be discontinued, treat with standard acne therapy using topical retinoids and/or benzoyl peroxide for mild cases, adding oral antibiotics (doxycycline or minocycline) for moderate cases, and reserving isotretinoin for severe or refractory cases—while avoiding additional topical or systemic corticosteroids which will worsen the condition. 1

Understanding Steroid-Induced Acne

Steroid-induced acne (acne medicamentosa) develops from excess glucocorticoid exposure, which triggers sebum production and sebaceous gland growth. 1 This differs from acne vulgaris in that steroid acne typically resolves spontaneously after drug withdrawal without scarring, though this is not an option when systemic steroids must be continued. 2

Primary Treatment Algorithm

For Mild Steroid-Induced Acne (comedones and few papules):

• Start with topical retinoids (adapalene, tretinoin, or tazarotene) applied once daily at bedtime 3
• Add benzoyl peroxide 2.5-5% applied once or twice daily to different areas or alternating with retinoid 3
• Use alcohol-free moisturizers with urea 10% to maintain skin barrier 3, 4

For Moderate Steroid-Induced Acne (multiple inflammatory papules/pustules):

• Continue topical therapy as above 3
• Add oral tetracycline antibiotics: doxycycline 100 mg twice daily or minocycline 50-100 mg twice daily for minimum 6 weeks 4
• Alternatively, use topical antibiotics (clindamycin 2% or erythromycin 1%) for localized lesions 4

For Severe or Refractory Cases:

• Consider oral isotretinoin starting at low dose (0.5 mg/kg daily) to minimize flare risk, gradually increasing as tolerated 5, 6
• If severe inflammatory nodules develop, isotretinoin combined with oral prednisolone may be necessary, though this creates a paradox when steroids are already the cause 5

Critical Management Principles

Never use additional topical corticosteroids for steroid-induced acne, as this perpetuates the problem despite short-term anti-inflammatory effects. 7 A controlled trial demonstrated that potent topical steroids (clobetasol propionate) produced no improvement in acne lesions. 7

Avoid systemic corticosteroids unless treating acne fulminans (a rare severe complication), where prednisolone 0.5-1 mg/kg daily combined with isotretinoin becomes necessary. 5 The coprescription of isotretinoin with systemic corticosteroids for routine acne is rare (0.24% of cases) and should remain so. 6

Essential Supportive Care Measures

• Avoid mechanical stress: no long walks without cushioned shoes, avoid heavy carrying without protective gloves 3, 4
• Avoid chemical irritants: no harsh soaps, solvents, disinfectants, or over-the-counter anti-acne products containing alcohol 8, 4
• Use gentle cleansers: soap-free shower gel, avoid hot water 4
• Apply broad-spectrum sunscreen SPF 15+ to exposed areas, reapplying every 2 hours when outdoors 8
• Moisturize regularly with alcohol-free emollients containing urea 10% applied three times daily 3, 4

Monitoring and Reassessment

Reassess response after 2 weeks of initiating or changing therapy. 3, 4 If no improvement occurs:

• Verify medication adherence and proper application technique
• Consider bacterial culture if pustules or crusting suggest secondary infection 4
• Escalate to next treatment tier in the algorithm above

Special Considerations for Intralesional Steroids

If occasional stubborn nodular lesions develop despite systemic steroid therapy, intralesional triamcinolone acetonide 5-10 mg/mL can flatten nodules within 48-72 hours. 3 However, this is only appropriate for isolated lesions, not multiple lesions, and carries risk of local atrophy, pigmentary changes, and paradoxically, more steroid acne. 3

Common Pitfalls to Avoid

• Do not abruptly stop necessary systemic steroids for other medical conditions just to treat acne—work with the prescribing physician to use the lowest effective steroid dose 3
• Do not use topical steroids thinking they will reduce inflammation—they worsen steroid acne 7
• Do not start isotretinoin at full dose in severe cases, as this increases flare risk; begin at 0.5 mg/kg daily 5
• Do not overlook secondary bacterial infection, which presents with painful pustules, yellow crusts, or discharge requiring antibiotic therapy 4