CONTINUING MEDICAL EDUCATION Steroid-Induced Rosacealike Dermatitis: Case Report and Review of the Literature Amy Y-Y Chen, MD; Matthew J. Zirwas, MD RELEASE DATE: April 2009 TERMINATION DATE: April 2010 The estimated time to complete this activity is 1 hour. GOAL To understand steroid-induced rosacealike dermatitis (SIRD) to better manage patients with the condition LEARNING OBJECTIVES Upon completion of this activity, dermatologists and general practitioners should be able to: 1. Explain the clinical features of SIRD, including the 3 subtypes. 2. Evaluate the multifactorial pathogenesis of SIRD. 3. Recognize the importance of a detailed patient history and physical examination to diagnose SIRD. INTENDED AUDIENCE This CME activity is designed for dermatologists and generalists. CME Test and Instructions on page 195. This article has been peer reviewed and approved Einstein College of Medicine is accredited by by Michael Fisher, MD, Professor of Medicine, the ACCME to provide continuing medical edu- Albert Einstein College of Medicine. Review date: cation for physicians. March 2009. Albert Einstein College of Medicine designates This activity has been planned and imple- this educational activity for a maximum of 1 AMA mented in accordance with the Essential Areas PRA Category 1 Credit TM. Physicians should only and Policies of the Accreditation Council for claim credit commensurate with the extent of their Continuing Medical Education through the participation in the activity. joint sponsorship of Albert Einstein College of This activity has been planned and produced in Medicine and Quadrant HealthCom, Inc. Albert accordance with ACCME Essentials. Dr. Chen owns stock in Merck & Co, Inc. Dr. Zirwas is a consultant for Coria Laboratories, Ltd, and is on the speakers bureau for Astellas Pharma, Inc, and Coria Laboratories, Ltd. These relationships are not relevant to this article. The authors report no discussion of off-label use. Dr. Fisher reports no conflict of interest. The staff of CCME of Albert Einstein College of Medicine and Cutis® have no conflicts of interest with commercial interest related directly or indirectly to this educational activity. Steroid-induced rosacealike dermatitis (SIRD) Accepted for publication March 6, 2008. Dr. Chen was a transitional intern, MetroWest Medical Center– is an eruption composed of papules, pustules, Framingham Union Hospital, Massachusetts. She currently is a fel- papulovesicles, and sometimes nodules with tel- low in dermatology clinical research, Department of Dermatology, angiectatic vessels on a diffuse erythematous and Wright State University Boonshoft School of Medicine, Dayton, edematous background. It results from prolonged Ohio. Dr. Zirwas is Assistant Professor, Division of Dermatology, topical steroid use or as a rebound phenomenon The Ohio State University School of Medicine, Columbus. Correspondence: Amy Y-Y Chen, MD, 1 Elizabeth Pl, Suite 200, after discontinuation of topical steroid. There are Dayton, OH 45408 ([email protected]). 3 types of SIRD that are classified based on the 198 CUTIS® Steroid-Induced Rosacealike Dermatitis location of the eruption: perioral, centrofacial, presentation, the patient used betamethasone valer- and diffuse. Diagnosis of this disease entity ate ointment daily. Five days prior to presentation, relies on a thorough patient history and physical he ran out of betamethasone valerate. The rash examination. Treatment involves discontinuation began to appear the day after the steroid was stopped of the offending topical steroid and administra- and progressively worsened on a daily basis. tion of oral and/or topical antibiotics. Topical Based on the patient’s history and physical calcineurin antagonists should be considered as examination, steroid-induced rosacealike derma- alternative or adjunctive therapies for patients titis (SIRD) was diagnosed. The patient was who do not respond to traditional treatments. counseled on the expected course of the disease. Dermatologists may need to provide psychologi- Treatment was initiated with doxycycline 100 mg cal support during office visits for patients who twice daily, clindamycin phosphate lotion 1% once have difficulty dealing with the discontinuation of daily, and tacrolimus ointment 0.1% once daily. On topical steroid and/or the psychological impact of follow-up a month later, the eruption had decreased RELEASE DATE: April 2009 a flare. Epidemiology, pathogenesis, histopathol- in intensity by approximately 50%. TERMINATION DATE: April 2010 ogy, and differential diagnosis of the entity also The estimated time to complete this activity is 1 hour. are reviewed. Comment Cutis. 2009;83:198-204. The development of topical corticosteroids in GOAL the 1950s opened new doors for dermatologists To understand steroid-induced rosacealike dermatitis (SIRD) to better manage patients with Case Report previously faced with treating intractable dermatoses. the condition A 42-year-old man previously not seen by a der- Since then and with the introduction of high-potency LEARNING OBJECTIVES matologist contacted our office for an emergent corticosteroids in the 1970s, a new dermatosis related Upon completion of this activity, dermatologists and general practitioners should be able to: appointment. The patient reported having an to the application of topical steroids to facial skin, excruciating facial eruption of several days’ dura- given several different names, has been described in 1. Explain the clinical features of SIRD, including the 3 subtypes. tion that his primary care physician was concerned the dermatology literature. As Weber1 reported, the 2. Evaluate the multifactorial pathogenesis of SIRD. might have been a serious infection. Because of the first cases of rosacealike dermatitis in the United States, 3. Recognize the importance of a detailed patient history and physical examination to urgency of his presentation, the patient underwent Great Britain, Scandinavia, and West Germany each diagnose SIRD. immediate evaluation. appeared years after the first publication on the clini- INTENDED AUDIENCE On examination, there was diffuse background cal use of steroids in the respective countries. The 2 This CME activity is designed for dermatologists and generalists. erythema on the chin, cheeks, and forehead with first case was reported in 1957. Frumess and Lewis superimposed erythematous papules and pinpoint described a dermatosis of unknown etiology that CME Test and Instructions on page 195. pustules (Figure). On further questioning, it was resembled seborrheic dermatitis, which they named discovered that the patient had been prescribed a light-sensitive seborrheid. In 1964, the term perioral topical steroid for a facial rash more than a year dermatitis was coined by Mihan and Ayres.3 Sneddon4 ago. The steroid initially worked well, but stron- used the term rosacealike dermatitis in 1969 because ger formulations had been necessary to progres- the eruption resembled rosacea, a well-established sively control the eruption. In the month prior to entity. Leyden et al5 named the disease steroid rosacea Diffuse background erythema on the forehead with superimposed erythematous papules. VOLUME 83, APRIL 2009 199 Steroid-Induced Rosacealike Dermatitis in 1974. In 1976, the term steroid dermatitis resembling The diffuse type affects the entire face, forehead, rosacea was introduced.6 Numerous other terms have and neck.9 been used to describe this disease entity including but Pathogenesis—The pathogenesis of SIRD and not limited to rosacealike eruption from topical steroid its rebound phenomenon is multifactorial but can and steroid-induced rosacealike dermatitis. We prefer the be partially explained by several hypotheses. After latter because it not only indicates the morphology of prolonged application of a topical steroid, functional the lesions but also points out their relationship with and anatomic cutaneous changes begin to occur. topical steroids. Steroid-induced rosacealike dermatitis has been Epidemiology—Steroid-induced rosacealike der- described as an intolerance reaction of seborrheic matitis results from repeated application of a topical skin to topically applied steroids. The seborrheic steroid to the face. The duration of use necessary to type of skin seems to be an essential factor because produce SIRD can vary from days to several years. in some experimental studies, application of potent Two months is the average, but 6 months or more of steroids to healthy skin rich in sebaceous glands has application is common.6-9 Although it was believed resulted in typical rosacealike symptoms.1,5,9,20,21 that only high-potency topical steroids could pro- Topical steroids may inhibit collagen synthesis, duce SIRD, it is important to note that topical leading to dermal atrophy. The decrease in support- hydrocortisone 1% also can cause such an eruption ing connective tissue allows for the passive dilation after prolonged use.8 of blood vessels and easier visualization of dermal The exact incidence of SIRD is not known, but capillaries that clinically manifest as prominent tel- it is believed to affect women more than men. The angiectases and background erythema.22,23 most common age at presentation is 40 to 50 years1,9; The immunosuppressive effects of topical steroids however, it also has been described in infants, chil- may facilitate the overgrowth of various bacteria, dren, and elderly patients.10-17 Despite its morpho- yeast, Demodex mites, or other microorganisms in logic resemblance to rosacea, SIRD