Pattern of Inappropriate use of Topical Corticosteroid and Cutaneous Adverse Effects at a Tertiary Level Hospital in Kathmandu

law


Introduction
T opical corticosteroid (TCS) misuse is defined as inappropriate use of TCS in terms of its potency, formulation, frequency, duration, and indications for particular dermatological manifestations. 1 TCS are available either as single-ingredient steroid products or in combination with antibiotics or antifungals. 2CS are classified according to the British Association of Dermatology into four classes based on their potency: mild, moderate, potent, and very potent. 3he appropriate usage of TCS depends upon the nature of the disease, the patient's age, its severity and the location of the disease. 4hanges, acneiform eruption, steroid-induced rosacea, hypertrichosis, pyoderma, photosensitivity, contact allergy, periorificial dermatitis, etc. 5,6 In melasma, cutaneous adverse effects arise when the triple combination (mometasone furoate 0.1%, tretinoin 0.025%, and hydroquinone 2%) is used beyond the recommended duration of 4-8 weeks. 7n Nepal, there is a paucity of studies regarding the inappropriate of TCS.This study aims to determine the pattern of inappropriate topical corticosteroid use and the incidence of different cutaneous adverse effects, as well as to evaluate the class of topical steroid and its duration of use.These adverse effects result in economic drain, cosmetic disfigurement, and psychological distress for patients.So, this study emphasizes the urgency of implementing strict laws regarding the judicious use of topical steroids.

Materials and Methods
The following is a hospital-based descriptive crosssectional study conducted among 84 patients at the outpatient Department of Dermatology and Venereology of Tribhuvan University Teaching Hospital, Kathmandu, from October 2020 to September 2021 (12 months).The study was conducted after obtaining ethical approval from the Institutional Review Committee of the Institute of Medicine.Inclusion criteria included participants of all ages presenting with current use of a topical steroid on different body parts where it is contraindicated such as acne, lightening of skin color or fungal, bacterial, viral, and parasitic cutaneous infections.Participants applying triple combination in melasma for more than 12 weeks were included.Exclusion criteria were participants on oral corticosteroids or with comorbidities that could cause changes similar to topical steroid side-effects.Written, informed consent was obtained from the participants.The generic name of TCS used, duration of use, and initial cutaneous disease for which TCS was applied were recorded.On examination, the current cutaneous adverse effect due to TCS use was observed and noted.Topical corticosteroids used were classified into different classes as per the British Association of Dermatologists classification. 6Data were entered in SPSS version 26 and analyzed for descriptive statistics.

Results
Out of the 84 participants included in the study, 40.5% were male (n = 34) and 59.5% were female (n = 50).The age of participants ranged from 2 to 57 years, with the mean age being 30.4 + 9.1 years.The majority of participants, 77% (n = 65) used TCS as dispensed by pharmacists.Most of the participants used topical steroids either for the duration of 1 week to 1 month or for more than 12 months.(Table 1 Twelve cutaneous adverse effects were observed in the study population.A single cutaneous adverse effect was seen in 77.3% (n = 65) participants, and 22.6% (n = 19) had multiple coexisting cutaneous manifestations.Tinea incognito was the most common adverse effect seen in 24.3% (n = 25).On the face, the most common finding was an acneiform eruption seen in 14.6% (n=15).Other less common cutaneous adverse effects seen in 1 participant each were exacerbation of pre-existing scalp folliculitis, periorificial dermatitis, and steroid induced pyoderma.The most common coexisting cutaneous finding was tinea incognito with striae in 5 participants (6%) followed by telangiectasia with an acneiform eruption on the face in 5 participants (6%).(Table 3)

Discussion
Inappropriate use of TCS was found to be a major issue amongst the participants presenting to the dermatology outpatient department.Out of the 84 participants enrolled in our study, 50 (59.5%)were female and 34 (40.5%) were male.It was similar to the study done by Mahar et al., in which there were 250 (60%) female and 100 (40%) male participants. 1The number of female participants was found to be higher than male participants in both the studies.In our study, the mean age was found to be 30.4years (SD of 9.1), which is similar to the study done by Shrestha et al., where the mean age of participants was 29.09 years (SD of 12.512). 8The similarity in mean age in both the studies could be attributed to young patients being more concerned about their skin health and timely healthcare-seeking behavior.TCS was most frequently used for dermatophytoses in 59 cases (71.4%), predominantly in tinea corporis (n = 19) (22.6%), followed by melasma and skin lightening in 19 cases (22.6%).In a study done by Shrestha et al., TCS was inappropriately used mostly for dermatophytoses (69.2%) followed by melasma (18.7%) which was similar to our finding. 8Since dermatophytoses is a common skin manifestation due to high heat and humidity, it can cause troublesome itching.Participants first rely on topical steroids for rapid relief.Also, melasma is another common skin manifestation due to direct sunexposure and hormonal changes during pregnancy.Since it is cosmetically troublesome, especially for the females, they rely on TCS as a single ingredient or a triple combination.
A study done by Meena et   2 Since TCS provides a rapid initial symptomatic improvement in dermatophytoses and melasma, participants discontinue the use of TCS after a short period.Immediately after TCS cessation, there is a recurrence of initial symptoms or the development of cutaneous adverse effects.This compels people to visit dermatologists within a short period of time.
In this study, 77% of the participants used steroidcontaining topical medications as dispensed by pharmacists.In the study by Dey et al., 35.3% of the participants used steroid-based preparations provided by pharmacists. 5In our part of the world, people are less aware of the appropriate use of TCS, which has to be used only after consulting dermatologists.

Conclusion
Inappropriate use of TCS is a common problem in dermatology.Easy accessibility of TCS is the main contributory factor.This results in several difficult-totreat cutaneous adverse effects, posing a challenge for dermatologists.So, to alleviate this issue, the general public must be made aware of the proper use of TCS.Strict rules and regulations to dispense the topical steroids only after a prescription from doctor have to be implemented.

Table 1 :
) Duration of topical corticosteroid use

Table 2 :
Cutaneous disease for inappropriate topical corticosteroid use

Table 3 :
Cutaneous adverse effects due to inappropriate use of topical corticosteroids

Table 4 :
Inappropriate use of TCS by potency

Table 5 :
Cutaneous disease and frequency of topical corticosteroid use