Can Steroids Cause Acne?
Yes, both systemic corticosteroids and anabolic-androgenic steroids definitively cause acne, with corticosteroids listed as a common side effect and anabolic steroids causing acne in approximately 50% of users. 1, 2, 3
Systemic Corticosteroids and Acne
Corticosteroids are an established cause of acne, listed among the common side effects of oral steroid therapy alongside blurred vision, hypertension, weight gain, and other adverse effects. 1
Clinical Characteristics of Corticosteroid-Induced Acne
Sudden onset is the hallmark feature, with eruptions appearing within days to weeks of starting corticosteroid therapy, distinguishing it from typical acne vulgaris. 2
Monomorphous papular or papulopustular lesions appear uniformly, rather than the mixed comedones and inflammatory lesions seen in typical acne. 2
Distribution extends beyond the seborrheic zone (face, upper chest, back), often involving the trunk and shoulders more prominently. 2
Unusual age of onset may occur, with steroid acne developing in patients outside the typical adolescent/young adult age range for acne vulgaris. 2
Incidence and Risk Factors
Acute-onset steroid acne occurred in 2% of hospitalized patients receiving intravenous corticosteroids in a prospective study, though this may underestimate the true incidence with longer-term oral therapy. 4
Spinal cord injury patients may represent a particularly high-risk population for developing acute-onset steroid acne. 4
Pityrosporum Folliculitis Connection
Over 80% of patients with acneiform eruptions while receiving systemic steroids show significant Pityrosporum ovale colonization in affected follicles, suggesting a fungal component rather than purely bacterial. 5
Oral antifungal therapy (itraconazole) demonstrated superior efficacy compared to traditional anti-acne medications in treating steroid-associated acneiform eruptions. 5
This finding suggests that steroid acne may actually represent Pityrosporum folliculitis in many cases, particularly when presenting as discrete follicular papules/pustules on the upper trunk. 5
Anabolic-Androgenic Steroids and Acne
Anabolic-androgenic steroids (AAS) cause acne in approximately 50% of users, making it one of the most common and clinically important indicators of AAS abuse. 3
Clinical Significance
Acne serves as an important clinical indicator of AAS abuse, especially in young men aged 18-26 years who present with sudden-onset severe acne. 3
Both acne conglobata and acne fulminans (severe, scarring forms) can be induced by AAS abuse, representing serious dermatologic complications. 3
The mechanism involves direct androgenic stimulation of sebaceous glands and increased sebum production. 6
Clinical Recognition
Dermatologists should specifically recognize "bodybuilding acne" as a distinct presentation warranting inquiry about AAS use. 3
The sudden appearance of severe acne in a muscular young adult male should prompt direct questioning about performance-enhancing drug use. 3
Diagnostic Approach
When evaluating suspected drug-induced acne:
Document detailed medication history including drug onset, dosage regimen, and therapy duration. 2
Assess temporal relationship between drug introduction and acne onset (typically days to weeks for corticosteroids). 2
Examine distribution pattern - lesions beyond typical seborrheic zones suggest drug-induced etiology. 2
Evaluate lesion morphology - monomorphous papules/pustules favor drug-induced acne over typical acne vulgaris with mixed lesions. 2
Management Considerations
Drug withdrawal should be followed by improvement in acne lesions, confirming the diagnosis. 2
For corticosteroid-induced eruptions with follicular papules/pustules on the trunk, consider oral antifungal therapy (itraconazole) as first-line treatment rather than traditional anti-acne medications. 5
Traditional acne treatments (topical retinoids, benzoyl peroxide, topical antibiotics) remain appropriate for managing acne in patients who must continue corticosteroid therapy. 1, 7
Low-dose corticosteroids (prednisone, prednisolone, or dexamethasone) are paradoxically indicated for acne fulminans, but this represents a specific therapeutic indication rather than a causative relationship. 6
Important Caveats
Intralesional corticosteroid injections are recommended as adjuvant therapy for large acne papules or nodules, but should be used judiciously with lower concentrations to minimize local adverse effects including skin atrophy. 1
The distinction between true steroid acne and Pityrosporum folliculitis is clinically important because antifungal therapy may be more effective than traditional anti-acne treatment in steroid-associated eruptions. 5
Physicians are involved in illegal prescription and monitoring of AAS in approximately 32% of abusers, highlighting the need for appropriate counseling about dermatologic and systemic complications. 3