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Background Approaches to improve keloid scars include intralesional corticosteroid injections and fractional lasers exclusively. The combinative use of ablative fractional laser therapy and occluded topical corticosteroid as a drug delivery method enhances therapeutic outcome of two efficient scar therapy modules into one simple synergistic module. Aim To compare the therapeutic effect of combining two modalities of scar treatment, the first is fractional ablative laser treatment and the other is occluded topical corticosteroid to the standard use of intralesional steroid injection. Methods Keloids from thirty suffering patients were split faced into two identical parts; one part received an intralesional corticosteroid injection while the other part was treated first with fractional ablative 2940 nm Er: YAG laser followed by occluded topical application of steroid cream. Four treatment sessions were performed with 4-week interval between sessions. Every session was assessed photographically and using the Vancouver Scar Scale (VSS). Results The mean keloid VSS before treatment was 6.9 ± 1.9. After treatment, the mean keloid VSS of the injection side became 2.63 ± 2.09, and mean keloid VSS of the laser-treated side became 2.07 ± 2.02. Each of the treated halves showed a statistically significant improvement in their VSS. However, no statistically significant differences were observed for either of the treated halves over the other one. Conclusion Although intralesional steroids injection is the standard procedure for treatment of keloid scars, the use of ablative fractional laser-assisted delivery of topical steroid can offer a safer and a better aesthetic treatment option.

A 47-year-old female patient undergoing hyaluronic acid injection in the glabella region suffered intravascular injection leading to marked discoloration (whitening) of the whole angiosome of the supratrochlear artery, extending to the areas of the anastomoses to the left upper eyelid, the dorsum of the nose, and the left sidewall of the nose. The syringe was immediately withdrawn while aspirating and prompt salvage counter-measures were taken, including application of warm compresses, vigorous massaging, oral administration of aspirin, repeated injections of hyaluronidase, and application of nitroglycerine paste on the affected area. The patient was followed up on a daily basis and the only additional treatment was the application of a combined antibiotic/steroid cream. The area affected healed satisfactorily with no scarring after 20 days. Our treatment protocol is discussed with special mention to the emerging role of hyaluronidase as the single most important rescue measure in the treatment of hyaluronic acid filler-related vascular adverse events. Level of Evidence: Level V, therapeutic study

The management of cicatricial ectropion resulting from epidermal growth factor receptor (EGFR) inhibitors is unclear. We describe two cases of bilateral cicatricial ectropion following the use of an EGFR inhibitor who were treated with oral doxycycline, topical ophthalmic steroid and antibiotic ointment to the eyelids, and topical facial steroid cream with lubrication. The first case resolved with discontinuation of panitumumab infusions along with institution of the aforementioned regimen. However, it is unclear whether the resolution was from discontinuation of the infusions or from the instituted regimen. The second case resolved without a dose adjustment of cituximab. This case may provide support for the use of this regimen prior to discontinuation of the offending agent, as there was a successful outcome without alteration of the infusions. Additional cases are necessary to determine if this is a successful means of treating bilateral lower-lid cicatricial ectropion from EGFR inhibitors.

Necrobiosis lipoidica is an idiopathic dermatosis of unknown origin, occurring mainly in patients with diabetes. Splenic abscesses are rare entities. We report a case with concomitant necrobiosis lipoidica and splenic abscess. A 58-year-old man presented to emergency center with a two day history of left upper abdominal pain, general malaise, and pyrexia. On both lower legs the patient had skin lesions. The contrast-enhanced computed tomography of the abdomen revealed splenomegaly and splenic abscess in the upper pole of the spleen. On the fourth day after admission, patient underwent open splenectomy. For the lesions on lower legs, by clinical examination, necrobiosis lipoidica was confirmed. The patient was treated by topical administration of steroid cream. After a 2 months follow-up, this treatment was not effective. Left upper abdominal pain and pyrexia in patient with necrobiosis lipoidica may suggest splenic abscess.

Background: Abuse of topical corticosteroids (TCs), especially over the face, is prevalent worldwide with India as no exception. Lack of adequate specialist services, the practice of self-medication and easy access over the counter (OTC) has resulted in widespread abuse. Aim of this study was to assess the magnitude of topical steroid abuse and its diverse cutaneous side effects in commercial sex workers.Methods: A cross-sectional analytical study was conducted among commercial sex workers (both females and transgender) attending the STI clinic in the study institution for 6 months. A semi-structured questionnaire was given and type of steroid cream used, frequency, duration, the reason for application and source of information for its use were recorded. Clinical patterns of side-effects were noted. Clinical photographs were taken. Descriptive statistical analysis was done, (SPSS 21.0).Results: Out of the total 180 commercial sex workers (CSWs), 80 were transgender and 100 were females. The most common steroid used was betamethasone valerate followed by the triple regimen containing mometasone. The reasons for TCs use were fairness (72%) followed by melasma (18%) and acne (10%). Side effects were seen in 77.5% of transgender and 66% of female CSWs. Common side effects noted were erythema (40%), acne (26%) and, pigmentation (18%).Conclusions: The main reason for TCs abuse in our country as a fairness agent is obsessiveness with fair skin colour. Various studies on TCs abuse were done in the general population but none of the studies focuses on a particular group as in this study.

Summary Background An uncircumcised male infant with a history of urinary tract infection (UTI), physiologic phimosis, and a normal renal ultrasound is a common patient referred to pediatric urology clinics. Topical steroid creams have been shown to effectively release physiologic phimosis. Objective The objective of this study was to test the hypothesis that use of steroid cream for physiologic phimosis is associated with a lower UTI recurrence in uncircumcised male infants with normal renal ultrasounds. Study design Uncircumcised males younger than 12 months referred for a UTI with a normal renal ultrasound were included. A longitudinal data set was created, and recurrent UTIs were identified. The proportion with a recurrent UTI was compared between those who received a prescription for a steroid cream for phimosis and those who did not. The morbidity of the initial and recurrent UTIs was also described. The association of recurrent UTI with vesicoureteral reflux (VUR) was also evaluated. Results A total of 192 uncircumcised males with a median age of 5.8 months (interquartile range [IQR]: 3.5–7.9 months) were included. Twenty-seven patients were treated with a course of betamethasone valerate 0.1% cream, and 165 were not ( Summary Table ). There were no significant differences between groups in the frequency of voiding cystourethrogram (VCUG), diagnosis of VUR, or use of continuous prophylactic antibiotics (CAP). During a median follow-up of 8.7 months (IQR: 3.1–17.5 months), none of the patients treated with steroid cream had a recurrent UTI compared with 27 of 165 (16%) patients not treated (P = 0.02). Among the 173 patients whose initial UTI was febrile, recurrent febrile UTIs occurred in no treated patients and 23 of 150 (15%) untreated patients (P = 0.047). Discussion The results of this study are consistent with those of a previous randomized trial of steroid cream for physiologic phimosis which found lower recurrent UTI in those whose foreskins became retractable. In addition, the results are consistent with the declining incidence of UTIs in uncircumcised males mirroring the natural history of physiologic phimosis resolving. This study is limited by its retrospective nature and non-standardized follow-up. Conclusion The use of steroid cream for physiologic phimosis is associated with a decreased risk of recurrent UTIs in uncircumcised male infants with a normal renal ultrasound. In this group, steroid cream for physiologic phimosis is a well-tolerated and simple alternative to circumcision to potentially decrease risk of recurrent UTI. Summary table . Patient characteristics and results Patient characteristic or result All patients (n = 192) Steroid cream group (n = 27) Non-steroid cream group (n = 165) P-value Median age in months at referral (IQR) 5.8 (3.5–7.9) 6.2 (3.6–8.4) 5.7 (3.4–7.8) 0.4 a Documented Febrile UTI 173 (90%) 23 (85%) 150 (91%) 0.3 b Catheterized specimen documented 132 (69%) 20 (74%) 112 (68%) 0.7 b VCUG obtained 118 (61%) 20 (74%) 98 (59%) 0.2 b VUR diagnosed 39 (20%) 5 (19%) 34 (21%) 0.9 b CAP use at any point 27 (14%) 6 (22%) 21 (13%) 0.2 b Median follow-up time in months (IQR) 8.7 (3.1–17.5) 12.1 (6.4–17.5) 7.8 (3.0–17.7) 0.3 a Recurrent UTI 27 (14%) 0 27 (16%) 0.02 b UTI = urinary tract infection; IQR = interquartile range; VCUG = voiding cystourethrogram; VUR = vesicoureteral reflux; CAP = continuous antibiotic prophylaxis. a Wilcoxan rank-sum test. b Fisher exact test.

Phimosis is described as condition in which prepuce or foreskin of glans penis is not retracted backwards resulting in poor narrowed stream of urine during micturition causing ballooning of prepuce along with recurrent attacks of balanoposthitis and Urinary Tract Infections (UTIs). Majority of new born boys do have non-retractile foreskin called as Physiological Phimosis. In Ayurveda phimosis is described as Nirudhaprakasha. Physiological phimosis usually does not require any kind of treatment as it resolve spontaneously within first couple of years mostly taking 3 to 6 years after which measures are considered to correct it surgically. Pathological phimosis is condition in which prepuce get adhered to glans secondary to adhesions or scarring made because of infection, inflammation or trauma. Pathological phimosis and physiological phimosis with recurrent attack of balanoposthitis and UTIs do require treatment. There are several treatment modalities are available according to severity of adhesions such as local application of steroid cream or oil, manual retraction, dilatation and Circumcision. In this review article we assess the various treatment modalities available in Ayurveda and contemporary medical science for better management of Phimosis.

Introduction: Topical corticosteroids (TCS) are widely misused. Uncontrolled use of steroids can cause undesirable adverse effects especially on face. Aim: The aim of this study was to assess the skin manifestations of TCS misuse over the face in the patients attending dermatology outpatient and to analyze various factors contributing to such misuse. Material and Methods: A total of 200 patients with facial dermatoses using topical steroids over face for minimum period of 1 month, reported between June 2010 and May 2011 were enrolled in the study. Details about the usage of topical corticosteroids and their side effects were recorded. The patients were educated about the misuse. Results: Majority of the patients were females (71%). The most common reason for misuse was acne (61%) followed by use as a fairness cream (23%). The average duration of usage was 6 months to 1 year, longest being 8 years. The drug most commonly misused was Betamethaone Valerate (71%). The commonest side effect noted was acne form eruptions (52%) followed by steroid dependent face (SDF) (36%). There were no cases of allergic contact dermatitis or perioral dermatitis. The exacerbation of the lesions on stoppage of steroid cream (90%) fairness effect (10%) were the reasons for continued use. (100%) were unaware of side effects of topical steroids. Conclusions: Steroids have been misused by patients on their own or by doctors for various reasons. Hence the awareness about their correct usage is essential.

Introduction: Topical corticosteroids are commonly prescribed for children with atopic dermatitis. Although generally well tolerated, long term unsupervised use can lead to ocular damage, including glaucoma. Much of the current literature focuses on the periorbital use in older patients. We present a case of an adolescent who suffered glaucomatous damage secondary to long term topical steroid use on her extremities. Methods: This is a case report of a child with extensive work-up for glaucoma suspect. Results: A 7-year-old African American female was found to have glaucomatous damage after using 2.5% hydrocortisone cream on her arms, legs, and back of neck twice daily continuously for 2 years. There were no other mechanisms that could have produced a secondary glaucoma. Congenital anomalous disk is a remote possibility. Discussion: Steroid cream use for atopic dermatitis is relatively common. The side effect profile of topical corticosteroids has been well documented and includes glaucoma. These patients may not have any visual symptoms, and can present at an advanced stage, with irreversible vision loss. Children with atopic dermatitis are especially susceptible to the systemic effects of steroids because of the damaged epithelial layer and also the body surface area to volume, both of which increase the bioavailability of the medication. Conclusion: Because topical steroids are commonly used, especially in children, patients need to be aware of the potentially dangerous side effects, including vision loss from glaucoma.

Background and purpose The aim was to investigate whether treatment with potent local steroids can reduce signs and symptoms of acute radiation dermatitis in breast cancer patients undergoing adjuvant radiotherapy (RT) compared to emollient creams. Material and methods The study was randomised and double-blinded. Patients with breast cancer who had undergone mastectomy or breast-conserving surgery were included when they started adjuvant 3-D planned RT. In all, 104 patients were randomised 2:1:1 to three treatment groups, i.e. betamethasone+Essex® cream, Essex® cream or Canoderm® cream. The patients themselves treated the irradiated area during the radiation period (5weeks) and two weeks after cessation of RT. Signs of RT dermatitis were measured qualitatively with RTOG clinical scoring and quantitatively by colorimeter. In addition, the patients' symptoms were recorded as well as the Fitzpatrick skin type. There was a statistically significant difference ( p =0.05) in skin reactions when assessed with RTOG in favour of the group treated with the potent steroid. Patient-related symptoms did not differ between the treatment groups. The effect of the steroid was prominent in three subgroups, i.e. (i) patients treated with ablation of the breast, (ii) patients receiving RT to the armpit and the supraclavicular fossa, and (iii) patients with Fitzpatrick skin type 1. Conclusions Treatment with betamethasone cream is more efficient than moisturizers for the control of acute RT dermatitis in patients treated with adjuvant RT for breast cancer.

Brimonidine gel, originally approved for the treatment of facial rosacea, causes direct vasoconstriction and possesses extensive utilization in dermatologic fields. A Q-switched (QS) neodymium-doped yttrium aluminum garnet (Nd:YAG) laser is generally used to treat solar lentigo (SL), often leaving unwanted postinflammatory hyperpigmentation (PIH), especially in dark-skinned individuals. A 58-year-old man with Fitzpatrick skin type IV presented to remove solar lentigines from his face. Prior to and after laser treatment, topical brimonidine gel and steroid cream were applied. In this study, we investigated whether topical application of the α-adrenergic receptor agonist brimonidine could reduce PIH after QS laser treatment of lentigine in a dark-skinned patient.

Phimosis, owing to the presence of a preputial fibrotic ring, is surgically treated in 1% of children. During the last decade, however, topical steroid treatment has been proposed for phimosis.We present a double-blind study comparing 0.1% mometasone furoate topical cream vs moisturizing cream (placebo) for the treatment of phimosis. Children aged from 2 to 13 years (n = 110) presenting with phimosis (Kikiro's classification grade 5) and scheduled for circumcision were included in this trial. The patients were evaluated after 8 weeks of topical treatment with moisturizing cream (n = 54) or steroid cream (n = 56). Nonresponders from both groups received an additional 8 weeks of steroid cream treatment.In the steroid group, the ring disappeared and glans exposure was obtained in 49 (88%) of 56 patients vs 28 (52%) of 54 patients in the placebo group (P.05). After a second treatment, in the steroid group, 5 of the 7 patients were finally cured vs 22 of the 26 in the placebo group (P.05). Two children with persisting phimosis (Kikiro's retractability grade 5 and appearance grade 3) in the steroid group (4%) vs 4 children in the placebo group (7%) ended up receiving postectomy.The present investigation adds up and supports the effectiveness of phimosis topical corticoid treatment. Nevertheless, hygiene and preputial traction, when appropriately performed, seem to play an important role in the disappearance of the phimotic ring as well. New studies are necessary to confirm if this is true or not.

Case Presentation An 8 month-old boy was referred to the endocrinology clinic for concerns of growth failure since 3 months of age. He was born full term with a birth weight of 2.67kg and a length of 45cm. His parents noticed that he was not growing well from 3 months of age. However, his weight gain remained more than satisfactory and he gained 700g in the past month. This infant was otherwise in good health, apart from atopic dermatitis, for which the parents had been applying a daily cream with good effect. He was breast fed until 2 months of age and weaned onto solids at 6 months of age. On examination, the infant had a moon face with hypertrichosis, facial telangiectasia and prominent supraclavicular fat pads. His recumbent length was 62cm (

Labial adhesions, also known as labial agglutination, are a common finding in prepubertal adolescents. They are defined as fusion of the labia minora in the midline or are termed vulvar adhesions when they occur below the labia minora (inner labia). Patients are often asymptomatic but might present with genitourinary complaints. The decision for treatment is based on symptoms. The mainstay of treatment in asymptomatic patients is conservative, with careful attention to vulvar hygiene and reassurance to parents. In symptomatic patients, topical treatment with estrogen and/or steroid cream is often curative. Less often, corrective surgery is necessary. Recurrence is common until a patient goes through puberty. These recommendations are intended for pediatric and gynecologic health care providers who care for pediatric and adolescent girls to facilitate diagnosis and treatment.

Introduction: Cutaneous burns are a common cause of morbidity following direct current (DC) cardioversion. We designed a prospective double-blinded controlled study to determine whether the application of steroid cream prior to cardioversion reduces their incidence and severity. Materials and methods: Two hours before elective DC cardioversion, we applied betamethasone 0.1% cream or placebo cream over sternal and apical pad sites in 56 patients, with patients acting as their own controls. Two hours after cardioversion, a separate blinded observer measured the visual analogue pain score (VAS), sensory and pain detection thresholds, skin temperature and erythema index at sternal and apical pad sites. Results: The study had an 80% power to detect a 50% difference in VAS at 2 h, accepting an α error of 0.05. There was no difference between pain at 2 or 24 h, skin temperature, erythema index, sensory and pain detection thresholds at pad sites treated with steroid cream or control. Conclusion: Topical betamethasone 0.1% cream applied 2 h before elective DC cardioversion is no more effective than placebo at reducing the pain and inflammation from cardioversion burns.

A prolonged use of topical corticosteroids can result in Cushing syndrome, though this is less common than with oral or parenteral steroids. Most pediatric cases were due to application of topical steroids for diaper dermatitis. Adverse cardiovascular effects can occur in Cushing syndrome with significant long-term morbidity and mortality, though so far there have been no reports of cardiovascular complications due to excessive usage of topical steroids. We report a 2.5-month-old boy who rapidly developed severe Cushing syndrome induced by the misuse of topical clobetasol, a very potent steroid, without a doctor's prescription as a diaper rash cream, and developed moderate left ventricular hypertrophy and pericardial effusion.

Background: Recently, topical steroid application has been shown by a small number of studies to be an effective alternative to circumcision for the treatment of phimosis. However, only potent or very potent corticosteroids have been more thoroughly studied in this treatment option. A prospective study was conducted to determine whether comparable results could be achieved using a weaker steroid cream. Methods: Boys, 3–13 years of age, with non-retractable foreskin due to a tight ring at the tip were offered the regimen of twice-daily preputial retraction and topical application of 0.02% triamcinolone acetonide cream. The degree of preputial retractability was assessed at presentation and at 4 and 6 weeks of treatment. Success was defined as full retraction or free retraction up to agglutination of the foreskin to the glans. Results: Eighty-three boys completed the treatment. Successful retraction was achieved in 48/83 (58%) patients after 4 weeks and 70/83 (84%) patients after 6 weeks of application. The overall response rate aggregated from six published series using 0.05% betamethasone was 87% at 4 weeks and 90% on completion of treatment. Thus, the results appear inferior when analysed at 4 weeks but compare favourably with those reported for a more potent steroid on completion of the full course of treatment. Conclusions: Even though the triamcinolone cream used in the present study is less potent than the more commonly used 0.05% betamethasone valerate cream, it could effect comparable improvements in foreskin retractability after 6 weeks of treatment.

Volunteer studies were carried out to assess the effect of a hydrocolloid containing dermatological patch (Actiderm) on the skin blanching activity of triamcinolone acetonide applied in a range of topical vehicles. Multiple blanching assessments were carried out following different application times (up to 72 h). The series of response/time profiles generated enabled the effect of different dosing regimes to be evaluated by comparing changes in peak response and cumulative area under the curve. Actiderm markedly increased the topical bioavailability of triamcinolone acetonide from creams and alcoholic solutions: similar activity to that produced by Saran Wrap occlusion was achieved. In contrast, only a slight effect on bioavailability from an ointment application was demonstrated. When using Actiderm both the concentration and quantity of steroid cream applied can be reduced considerably from that used in conventional twice daily non-occlusive therapy whilst still achieving greater activity.

The dermal toxicity of four antimicrobial-steroid cream formulations, tolnaf-tate 1%/hydrocortisone 0.5% (TH), clotrimazole 1%/hydrocortisone 0.5% (CH), clotrimazole 1%/betamethasone 0.06% (CB), and clotrimazole 1%/gentamkin 0.1%/betamethasone 0.05% (CGB), was compared in separate studies. All cream formulations were applied to the intact skin of rabbits for 21–25 consecutive days. For comparison, two control groups were used in each study: one dosed with the appropriate vehicle and one nmfreated group.The results of these studies have shown that erythema produced on intact rabbit skin by each of the medicated cream formulations was equivalent or slightly less than that produced by each of the corresponding vehicles. There was no significant difference between the medicated and vehicle creams in the time of onset of erythema or in the incidence of edema, atonia, papules, pustules, desquamation, wrinkling, fissuring, or skin thickness. These findings suggest that tolnaftate, hydrocortisone, clotrim...

OBJECTIVES: Topical steroids have been advocated as an effective alternative treatment to circumcision in boys with phimosis. We evaluated the effectiveness of topical steroid therapy compared to a placebo neutral cream in 240 patients with phimosis. METHODS: A prospective study was carried out over a 24-months period, on an out-patient basis on two groups of patients with phimosis. One-hundred twenty patients applied a steroid cream twice a day for 4 weeks, and another group of 120 pts used a placebo cream twice a day for 4 weeks. Patients were assigned to either group by a computer-generated random choice. RESULTS: All patients in our series completed the two treatment periods without interruption. At a median follow-up of 20 months (6-30 months) therapeutic success was obtained in 43.75% (99/240) of cases, independently of the protocol. In particular, therapeutic success was obtained in 65.8% (79/120) of cases in the steroids group and in 16.6% (20/120) of cases in the placebo group, the difference being statistically significant (P < 0.0001, Mann-Withney test). CONCLUSION: Our study shows that topical steroids represent a good alternative to surgery in case of phimosis. Steroid therapy using monometasone furoate 0.1% in our series gave better results that placebo with an overall efficacy of 65.8%. In patients where a phimotic ring persist after steroid therapy, circumcision is mandatory.

Background Modern radiotherapy (RT) reduces the side effects at organ at risk. However, skin toxicity is still a major problem in many entities, especially head and neck cancer. Some substances like chemotherapy provide a risk of increased side effects or can induce a "recall phenomenon" imitating acute RT-reactions months after RT. Moreover, some phototoxic drugs seem to enhance side effects of radiotherapy while others do not. We report a case of "radiation recall dermatitis" (RRD) one year after RT as a result of taking hypericin (St. John's wort). Case report A 65 year old man with completely resected squamous cell carcinoma of the epiglottis received an adjuvant locoregional RT up to a dose of 64.8 Gy. The patient took hypericin during and months after RT without informing the physician. During radiotherapy the patient developed unusual intensive skin reactions. Five months after RT the skin was completely bland at the first follow up. However, half a year later the patient presented erythema, but only within the area of previously irradiated skin. After local application of a steroid cream the symptoms diminished but returned after the end of steroid therapy. The anamnesis disclosed that the patient took hypericin because of depressive mood. We recommended to discontinue hypericin and the symptoms disappeared afterward. Conclusion Several drugs are able to enhance skin toxicity of RT. Furthermore, the effect of RRD is well known especially for chemotherapy agents such as taxans. However, the underlying mechanisms are not known in detail so far. Moreover, it is unknown whether photosensitising drugs can also be considered to increase radiation sensitivity and whether a recall phenomenon is possible. The first report of a hypericin induced RRD and review of the literature are presented. In clinical practise many interactions between drugs and radiotherapy were not noticed and if registered not published. We recommend to ask especially for complementary or alternative drugs because patients tend to conceal such medication as harmless.

To develop a practice guideline report on the questions: What are the optimal methods to prevent acute skin reactions (occurring within the first 6 months of irradiation) related to radiation therapy? What are the optimal methods to manage acute skin reactions related to radiation therapy? Cancer Care Ontario’s Supportive Care Guidelines Group (SCGG) conducted a systematic review of literature on this topic. Evidence-based recommendations were formulated to guide clinical decision making, and a formal external review process was conducted to validate the relevance of these opinions for Ontario practitioners. Twenty-eight trials meeting the inclusion criteria were identified. Of the twenty-three trials that evaluated preventative methods, washing was the only practice which significantly prevented skin reaction. Some evidence suggested topical steroid creams and calendula ointment might be effective. None of the five trials evaluating skin reaction management detected a positive effect using steroid cream, sucralfate cream, or dressings. Skin washing, including gentle washing with water alone with or without mild soap, should be permitted in patients receiving radiation therapy to prevent acute skin reaction. There is insufficient evidence to support or refute specific topical or oral agents for the prevention or management of acute skin reaction. In the expert opinion from the SCGG, the use of a plain, non-scented, lanolin-free hydrophilic cream may be helpful in preventing radiation skin reactions. In addition, a low dose (i.e., 1%) corticosteroid cream may be beneficial in the reduction of itching and irritation.

A 52-year-old man was referred to the dermatology clinic for a persistent rash on his face and lips of 5 months' duration, despite the use of a mild steroid cream prescribed by his primary care physician. He noted that the rash had “seemed to spread” and was now on his hands as well. In addition, he had hard nodules on his fingers that had become noticeable in the previous 2 weeks. He reported a history of long-standing gastroesophageal reflux disease that was well controlled with proton pump inhibitors. Physical examination revealed matlike telangiectasias on the patient's face, lips, and hands (Figure ​(Figure11), hard subcutaneous nodules on fingers that appeared edematous and tight (Figures ​(Figures22 and ​and33), and a loud P2 component on cardiac auscultation. Upon further questioning, he reported a long history of cold intolerance, with cold weather causing aching hands that “turn blue.” Figure 1 Matlike telangiectasias on the face and lips. Figure 2 Nonpitting edema of hands and fingers with matlike telangiectasias. The skin is waxy and tight with no hair on the dorsum of the hands. (File photo of another patient with the same disorder.) Figure 3 Subcutaneous calcium hydroxyapatite nodules in the fingertips. DIAGNOSIS: CREST syndrome.

The skin is the largest organ in the body, is vital to the maintenance and balance of the body and is an indispensable structure for human life. The maintenance of healthy skin depends on factors such as moisture, the nutritional status of the patient and mechanical forces. Clever use of barrier films, barrier creams, emollients, steroid cream and observation of the patient's tissues over time, will protect the skin from external stimulants.

Lichen sclerosus is an inflammatory disease of unknown etiology affecting the anogenital skin and associated with the development of squamous cell carcinoma. It is not known whether long-term topical treatment with a potent steroid can cure this disease and thus prevent malignant evolution.To analyze the rates of remission, recurrence, and chronic evolution of vulvar lichen sclerosus (VLS) treated with 0.05% clobetasol propionate ointment and determine whether this treatment can decrease the risk of malignant evolution.Prospective study, conducted between 1981 and 2001, of 83 women with VLS who were treated until complete clinical and histologic remission and followed up for evidence of clinical and histologic recurrence (median follow-up, 4.7 years).Dermatology department of a large urban teaching hospital.Complete remission was obtained in 45 patients (54%). The probability of remission was significantly associated with age (P.001). The estimated incidence of remission at 3 years was 72% in women younger than 50 years, 23% in women aged between 50 and 70 years, and 0% in women older than 70 years. The incidence of relapse was estimated to be 50% at 16 months (95% confidence interval, 30%-64%) and 84% at 4 years (95% confidence interval, 57%-94%). Age had no effect on relapse prevalence. The 8 observed vulvar squamous cell carcinomas (9.6%) occurred in previously untreated or irregularly treated VLS lesions.Treatment with a potent steroid cream can improve but does not cure VLS in women older than 70 years, probably because of a long disease evolution. In younger patients who achieve complete remission, it seems to have only a temporary effect. Although a protective effect from malignant evolution is suggested (carcinoma developed only in nontreated or irregularly treated VLS lesions), the number of seemingly protected patients was too small to be statistically significant.

QUESTION: A 50-year-old woman is seen for evaluation of a facial eruption that has been present intermittently for at least 5 years. The process is located on her mid and lower face. She has used the topical corticosteroid creams diflorasone diacetate 0.05% and hydrocortisone valerate 0.2% for a prolonged period. Indeed, she presents crimped empty tubes to us in hopes of refills (figure 1). These preparations provide temporary relief, but the eruption always returns. Figure 1 Nearly empty tubes of medium- and high-potency topical steroids presented by patient Examination shows that she has a light complexion and marked erythema and scaling of the lower face, extending up to the cheeks. The lower lids show minor involvement (figure 2). The eruption spares the vermilion border of the lips and the lips themselves. Figure 2 Marked erythema and scaling of the patient's lower face What are the diagnosis, differential diagnosis, and treatment of this condition? What role do prescription topical steroids play in this eruption? ANSWER: This patient has steroid-induced perioral dermatitis, a condition marked by perioral or periorbital erythema and scaling with or without papules that characteristically shows a rim of sparing around the vermilion border of the lips. The process usually starts in a perioral distribution with later involvement of the chin, nasolabial folds, and occasionally the eyelids. It occurs mostly in women. The differential diagnosis includes classic perioral dermatitis, rosacea, and acne. Perioral dermatitis can begin by itself and is seen mostly in women aged 15 to 50 years,1 although it also may rarely affect prepubertal children of both sexes.2 Perioral dermatitis can become steroid-induced perioral dermatitis after prolonged use of topical corticosteroids on the face. Steroid-induced perioral dermatitis is differentiated from common perioral dermatitis by history and clinical behavior. Patients with rosacea and acne can also develop steroid rosacea, steroid acne, or the red-face syndrome after corticosteroid abuse.3 Steroid-induced facial dermatoses tend to have more erythema, inflammation, and scaling than their noniatrogenic counterparts. Mid- or high-potency topical corticosteroids are known to exacerbate perioral dermatitis, acne, and rosacea. They often initiate a cycle of temporary relief and increasingly severe flare-ups on attempt to stop the medicine. This has been described as an “addiction” of the skin to the steroid, requiring increasingly larger and more frequent applications of steroid creams to bring relief.4 Although temporarily reducing the inflammatory reaction, the steroid may increase the overgrowth of the bacteria through local immunosuppression. We have observed that patients with steroid-induced perioral dermatitis often present with vigorously squeezed tubes of corticosteroids that they have used for many months to years. These patients have tried to extract as much of the precious cream as possible to counter the latest flare of the dermatitis. Thus, we term this presentation the “tortured tube” sign. Treatment involves cessation of the topical steroid. Often this regimen initially results in moderate to severe flare-ups of the eruption. The administration of tetracycline, 500 mg by mouth twice a day, and cold tap water compresses will help to alleviate the inflammation. The lesions typically resolve after a few weeks, but occasionally may last as long as 6 months. To ensure therapeutic success, the physician must educate the patient about the course of the disease and the need to discontinue the use of topical corticosteroids. Prevention is more important than cure. Physicians should never prescribe mid- to high-potency topical corticosteroids for facial use without clear oral and written instructions that limit the time of application to no more than 1 to 2 weeks. Even weaker corticosteroid creams have been implicated in initiating facial disorders. Refills of these medicaments should not be given over the phone. A 15-gram tube of a steroid cream may last a patient 6 to 12 months when used only on the face and is sufficient to cause cutaneous addiction with the development of uncomfortable and unsightly dermatoses. In this case, on follow-up several months later, the patient's rash had resolved (figure 3). Figure 3 Resolution of the patient's rash several months after abstaining from steroid use

Referrals of younger patients with ‘painful piles’ who have already applied steroid cream are common. Ninety per cent of acute anal fissures heal, but in nearly all those that …

EDITOR, — C J McLean and colleagues draw attention to the dangers of long term periocular use of strong steroid ointments and …

Sir .—I attended the Fall meeting of the American Academy of Pediatrics in Chicago last year. Everybody seemed to love the trinkets, snacks, pens, flashlights, and other paraphernalia given away by convention exhibitors. As I watched the escalators to the exhibit hall, participants descended with only their programs in hand; but on the way up, many carried shopping bags bulging with "goodies." As listed below, most of the giveaways did not bear the slightest relationship to the products being promoted, but who cared? They were free! Exhibitor's Giveaway Product Item Steroid cream Book underliner Immunoglobulin Writing pen Allergy medication Instant photo Fever control medication Windbreaker Sore throat spray Coffee mug Skin cleansing Rubber bath products toy Laxative Doughnuts Digestive enzyme T-shirt Sun cream Beach ball Pain reliever Coffee mug Skin ointment Travel contest We all know that you do not get something for nothing. The cost of these promotion items—one

A 68-year-old woman presented for care of another problem. During the physical examination of this otherwise normal, healthy woman, striking atrophy of the terminal phalanges of the fingers was noted in both hands. This atrophy involved both dorsal (Fig 1) and palmar (Fig 2) surfaces of the fingers, with a sharp limitation at the level of the proximal interphalangeal joints. Only the right little finger was spared. The overlying skin of the terminal phalanges showed severe thinning, erythema, and scaling. The nails exhibited diffuse yellow discoloration and subungual hyperkeratosis, whereas the nails of both thumbs were lost. The toes, toenails, teeth, and hair showed no evidence of alterations, and the mucous membranes were normal. The patient applied a high-potency fluorinated steroid cream topically on the distal areas of the fingers on a daily basis for the last 20 years. This therapy was initiated in the early 1960s because of fingertip

A shipwright developed a delayed bullous irritant dermatitis from contact with a bis-tri-butyl tin oxide (TBTO) containing antifouling paint. He subsequently developed sensitization to 4-chloro-m-cresol, a constituent of a steroid cream. No cross sensitivity to 4-chloro-3,5 xylenol was seen. Low concentrations of 4-chloro-m-cresol in pet. may elicit a true positive reaction. TBTO is a strong irritant which will produce delayed bullous reactions in industrial use and on patch testing at 0.1% aqueous.

15 patients with melasma were treated with betamethasone 17-valerate in a cream base containing DMSO. One patient with secondary pigmentation was also entered in the trial. In nine patients results were favourable and in three results were moderate. This effect could be ascribed to the steroid.

The percutaneous absorption and disposition of tritium-labeled diflorasone diacetate (6α,9α-difluoro-16β-methyl-11β,17α, 21-trihydroxypregna-1,4-diene-3,20-dione 17,21-diacetate) was studied in the rat, monkey and man, after a single cutaneous application of the radioactive 0.05% steroid cream. The extent of percutaneous absorption (as measured by excretion) was high in both the rat and monkey, being 88.2% (SD = 6.1%; n=8) and 49.6% (SD = 15.5%; n=4) respectively, of the net administered dose. On the other hand, only 1.1% (SD = 0.5%; n=6) of the net dose was excreted in man, a result compatible with similar data reported for other corticosteroids. The difference may be attributed to anatomical variation in skin structure ( e.g. , greater density of hair follicles and hence increased pilo-sebaceous penetration). Evidence for the retention of the unexcreted diflorasone diacetate in the well-known stratum corneum reservoir was provided by the recovery of small but significant quantities of radioactivity from the surface of the skin of the application sites of all the human volunteers at the termination of the study. The penetration of diflorasone diacetate- 3 H through abnormal skin (abraded to produce hyperemia) was compared with that through normal skin in the animals, but no significant differences were observed except for the prolonged retention of drug-related radioactivity on the abraded skin of the monkeys. The rate of combined urinary and fecal excretion of drug-related radioactivity reached a maximum during the 24–72 hr period after drug administration in the rat and monkey, and during the 48–96 hr period in man. The redistribution of the applied diflorasone diacetate- 3 H radioactivity from the application site to the rest of the skin was observed in the monkey.

Adult nude mice had 1.5 to 1.0 meshed split-thickness human skin applied to an excised area of their back. The animals were then randomized into two groups, one of which had a steroid cream applied to their graft on alternate days. The other group had no ointment applied and served as a control. The wounds were measured on a weekly basis and the rate of wound contracture was found to be identical. Topical steroids would thus appear to offer no benefit in the prevention of scar contracture.

A 7-month-old male infant was brought to this department by his parents without referral from his family doctor. For 6 months he had suffered from a rash in the napkin area which was resistant to various treatments. These had included a variety of 'barrier' creams, topical antifungal agents and Hydrocortisone ointment. Recently the parents had become concerned by the development of two lesions within the napkin area. Examination revealed a dry erythematous papular rash over the lower abdomen, the centre of which contained two raised, bluish-purple, nodular lesions of differing size and shape. The proximal lesion was rounded and 05 cm in diameter, whilst the distal lesion was oval-shaped with dimensions of 5 x 2 cm. (Fig. 1) The patient was referred to a dermatologist who diagnosed Granuloma Gluteale Infantum. The infant was admitted to hospital for observation and treatment. Hydrocortisone cream was applied to the granulomatous areas and a fluorinated steroid cream to the remainder of the rash. Both the napkin dermatitis and granulomas improved on this regimen. The patient remained on this regimen for 3 weeks, requiring only barrier cream thereafter. Subsequent review over 6 months demonstrated slow resolution but not complete healing of the granulomas, without evidence of scarring.