Patterns of use of topical steroids by

patients with tinea corporis/cruris and

parameters determining development
of atrophogenic effects

Steroid abuse in tinea corporis/cruris

Dr. Khushboo Sethia

Junior Resident
Department of Dermatology, Dr
Ram Manohar Lohia Hospital and
PGIMER, New Delhi
Background
Although topical corticosteroid (TCS) abuse is considered an important contributory
factor towards causing recalcitrant dermatophytoses, the trends of TCS use in tinea
corporis/cruris have not been specifically evaluated.
Introduction
Although topical corticosteroid (TCS) abuse is considered an important contributory
factor towards causing recalcitrant dermatophytoses, the trends of TCS use in tinea
corporis/cruris have not been specifically evaluated.

Recent studies from the country report a high incidence of topical corticosteroids
(TCS) misuse among patients with tinea corporis/cruris.1,2 TCS abuse has been cited
as a possible factor in the development of recalcitrant dermatophytic infections.3 The
synergism with local host immunity is particularly relevant to the action of fungistatic
drugs and hence its suppression is likely to lower their efficacy.4There have been
many systematic studies on TCS abuse on face and those broadly covering many
conditions, 5-9but studies specifically focusing on dermatophytoses of the glabrous
skin are scarce.10,11 Hence we conducted this study to specifically look into the trends
of TCS abuse in patients with tinea corporis/cruris and its possible consequences.
Aims
The aim of this study was to record the patterns of TCS use in patients with tinea
corporis/cruris/faciei and analyze the usage patterns in relation to development of
atrophogenic adverse effects of TCS.

The study was conducted with the following aims:

1. To collect data on the trends of use of TCS in our patients with tinea
corporis/cruris.
2. To evaluate for the incidence of cutaneous signs of TCS abuse among these
patients.
3. To correlate the presence of the signs of TCS abuse with various demographic
and TCS usage parameters.
Methodology
100 consecutive patients with a clinical diagnosis of tinea corporis/cruris/faciei who could recall the TCS
preparation/s used by them till the point of presentation were included. Questions regarding amount of usage,
prescribers and reasons for usage were asked as per a pre formulated questionnaire.
Materials and Methods
The study was conducted over 12 monthsfrom January 2018 to December 2018, with prior approval of the institutional ethics
committee. It was a questionnaire based study including hundred consecutive consenting adult patients, fulfilling the following
inclusion criteria:
1. A clinical diagnosis of tinea of the glabrous skin including tinea corporis,cruris and faciei
2. Who had used or were using a TCS preparation over their tinea lesions and who
3. Remembered the names of products used or had packs to show for them.
Patients with isolate involvement of palms/soles/nails, without glabrous skin involvement were excluded. A detailed clinical
assessment was done as per a pre formulated proforma. Specifically, questions were asked regarding the
prescriber,preparation/s used, reasons for not consulting a dermatologist before, reasons for continuing to take refills, rough
estimate of usage, effect of treatment, awareness of adverse effects of TCS, apparent benefit achieved with application and any
side effects noted. The extent of lesions, the degree of inflammation and the presence of cutaneous adverse effects attributable
to TCS application were noted.
The data was entered in Microsoft excel. After data cleaning the data was imported in SPSS ver. 16.0. Descriptive tabulations
were drawn and analysed. The qualitative data analysis was done using Chi square test or Fischer’s exact test. After checking for
normality, appropriate correlation test was applied. A ROC curve was attempted for the duration of steroid use as well as the
total steroid amount. A P value of <0.05 was taken as significant.
Results
Most patients had used very potent TCS, with the combination of TCS, antibacterial and antifungal being the
commonest used preparation. General practitioners and chemists were the top prescribers of TCS preparations.
Unavailability of dermatologists in vicinity and convenience of taking drugs from GPs/chemist were most commonly
cited reasons for not reporting to a dermatologist before. Most patients used TCS intermittently. Cutaneous signs of TCS
abuse were present in 44 patients. The total duration of TCS use, duration of disease and total amount of TCS used
correlated significantly with the presence of cutaneous signs of TCS abuse, while the potency of TCS used did not.
Hundred consecutive patients were enrolled as per the inclusion criteria. The demographic profile and general data on disease is presented in Table 1. The prescription
trends are mentioned in Table 2.
Only 25% patients had consulted a dermatologist before. The most common reasons for not consulting a dermatologist before were “none available in the vicinity” (31%)
and “convenience of taking treatment on own” (30%). Others did not consult a dermatologist as they were unaware of the need for it (10%), cost involved in consulting a
dermatologist (12%) and other unlisted reasons (6%). A few patients (14%) gave two or more reasons for the question. Reason for dermatologist consultation at this
instance were “prolonged disease not getting better after trying many resorts” in the majority of patients (85%), “recent worsening” (9%) and “on someone’s advice” (16%).
Treatment duration was specified by prescriber in only 23% patients varying from 1week to 6 months. The patients continued the TCS preparation beyond the specified
duration/kept taking refills due to immediate relief on application (71%) and because of no clear usage instructions given (30%). Most patients applied the TCS preparation
on all lesions (96%), while the remaining few applied only on the most bothersome ones. The trends of steroid use and their association with presence of cutaneous signs of
steroid abuse are presented in Table 3. The most common formulations and their costs are mentioned in Table 4.Twenty-seven patients were using more than one TCS
preparation and 2 patients had also taken intramuscular steroids.
Seventy-six patients (76%) reported partial improvement and 17 (17%) patients had apparent complete improvement with the steroid preparation. Sixty-four patients
reported they had improvement in both appearance of lesions and pruritus, 18 had improvement in only pruritus, while 6 patients reported no improvement. Most patients
(63%) had recurrence within a week after stopping the TCS preparation. Twenty-four patients noticed change in skin (hypopigmentation, thinning, striae) in the area of
application. Only one patient was aware of the side effects of long term TCS use. This patient too had cutaneous signs of steroid abuse. Signs of steroid abuse were present
in 44 (44%) patients in the form of striae (n=29), (Figure 1A,B) hypo/de pigmentation (n=11), thinning (n=8), hypertrichosis (n=1) and tinea pseudoimbricata (n=1).
Other skin diseases were present in 6 patients (2 had urticaria, 1 had keratoderma, 1 had alopecia areata and 2 had acne). Past history of tinea was present in 7 patients.
Fourteen patients were receiving therapy for some systemic disease treatment (oral hypoglycaemic agents:7, antihypertensives:1, NSAIDS: 1, thyroxine: 2,
antidepressants:1, and other/ unknown medication :4).
Extent of involvement (BSA) was <10% in 74% patients, 10-30% in 22% patients and >30% in 4% patients. Most common sites involved were lower limbs and intertriginous
Discussion
The rapid relief in inflammation of any cause, the prevalent practice of self medication for dermatological diseases and the easy availability of over the counter (OTC) steroid
creams are the reasons TCS have a high misuse potential. It has been observed in previous studies from the country that fungal infections form the commonest reason for TCS
abuse in our population.8,9 Chaudhary et al reported that 18.4% of their patients with tinea had used TCS before. 10
A large number of our patients suffered from disease for more than a year. Similar findings have been reported in other recent studies from the country emphasising the fact that
tinea corporis/cruris has now become a chronic infection of skin.1,2. The high prevalence among family members (36%) shows the high propensity of transmission of the
prevailing strain. GPs (47%) and unfortunately chemists (42%) form the first contact point for patients. The patients were mostly given a combination of steroid, antifungal and
antibacterial (52%), a strategy to “cover them all” with no knowledge of the etiology. Efforts directed specifically towards these two groups are likely to benefit in the fight
against steroid abuse. That most patients were aware of the disease requiring a dermatologist is an encouraging point. However, they preferred convenience of taking drugs on
their own to visiting a dermatologist. Similar to our findings, Dabas et al also reported that only a few patients had previously consulted a dermatologist for their skin lesions.
This reflects the larger belief among masses that any skin condition can be easily managed by the OTC “tubes”. A favourable trend is that patients recognise the merit of
specialist consultation as, “a prolonged disease not getting better” is the reason the majority (85%) finally consulted a dermatologist. The situation is however despite the fact
that a majority of the patients (73%) were educated till high school or above. The issue here is that the lay public does not treat the dermatologists as the first point of contact
for skin related issues and thus directed efforts at this may have far reaching benefits. Another concern is that there is a deep seated belief that the skin “tubes” are harmless
and may be used as per need. None but one of the patients were aware of the adverse effects of prolonged unsupervised TCS application. This is similar to observations by
Meena et al, wherein 98% were unaware of the adverse effects of TCS.8An apparent relief is the reason most continued the applications (n=71). Most (n=63) however noted that
the condition recurred within a week of stopping and understood that the disease was not cured by the creams.
Cost of treatment seems to an unlikely factor in prevalent TCS abuse in dermatophytoses. As is clear from Tables 4 and 6, the top 2 preparations used by the study group
(Fourderm, Quadriderm) are costlier than most topical antifungal preparations. A previous paper has highlighted the economic burden that prescription of combination products
entails, which can be reduced by substitution with only antifungal containing products.10
The modification of features with TCS use did not preclude the diagnosis over trunk, limbs or groins in most patients, although the modification over facial lesions was
considerable in many, with diagnosis being possible only with detection of more suggestive lesions at other sites. (Figure4A-D) The adverse effects of TCS on face also have
certain morphological differences from those seen elsewhere on the body and the greater modification of facial tinea lesions by TCS use has been observed before.6,7We
observed a tinea pseudoimbricata appearance in only one of the 100 patients.
It was an interesting finding that the potency of steroid did not significantly correlate with the presence of visible signs of steroid abuse. Further, the atrophogenic signs of TCS
abuse were seen in only 44% patients, despite the use of very potent (66%) and potent (13%) steroids by most. The atrophogenic side effects of TCS start with epidermal thinning
which precedes loss of dermal thickness.11Some controlled experiments have demonstrated that the skin thinning developing with short term use of select steroids
(betamethasone dipropionate and clobetasol propionate) is reversible upon discontinuation. This reversible phenomenon has been called as “pre-atrophy” and is probably
caused by a functional effect of reduced hyaluronic acid synthesis, not as yet accompanied by structural changes. 12,13,14 However, it becomes irreversible with extended durations
of application.12Further, atrophy develops slower with intermittent rather than continuous applications. 12,13 We observed that most of our patients used TCS intermittently as a
rescue treatment. Seventy eight patients had never used the preparations for more than a month at a stretch. The scenario seems to be different from TCS abuse for skin
Conclusions
Although very potent TCS preparations are most often abused by patients with tinea
corporis/cruris, the intermittent as per need use possibly rescued many from the
expected atrophogenic effects. The lack of the inherent propensity for patients to visit
the dermatologist at the first instance is a worrisome trend.
TABLE 1: Demographic profile and disease history

Feature No of patients
Age 15-80 years (mean 31.75 years)
Sex 74 males
26 females
Educational status Uneducated – 9
Primary-2
Secondary: 16
High school- 40
Graduate- 29
Post graduate- 4
Employment Skilled workers – 39
Unskilled workers – 27
Unemployed - 34
Disease duration <3 months- 26
3-6 months -18
6months – 1 year: 22
>1 year -34
Family history Present -36
Absent – 64
Table 2: Prescription trends

Variable Patient number

Prescription available Yes-15
No-85
TCS given by GP -47
Chemist -42
Dermatologist -16
Alternative medicine practitioners– 7
Neighbors -3
Self/family member – 1
Other specialists (internal medicine/gynecologist)
–2
More than one source – 18
Systemic antifungals taken previously (n=41) Fluconazole – 21
Itraconazole -12
Ketoconazole -2
Terbinafine -4
Griseofulvin – 2
TABLE 3: Trends of steroid use and correlation with presence of cutaneous
signs of steroid abuse

Maximum continuous ≤1 week 18 No significant

usage >1week-1 month 60 association(p=0.813)
>1month- 3 months 14
>3 months 8

Total duration of steroid ≤1 week 2 Statistically significant

use (data of 63 patients) >1week-1 month 18 association (p=0.0016)
>1month- 3 months 16
> 3 months-1 year 24
>1 year 3
Total steroid used (data ≤10 grams 3 Statistically significant
of 63 patients) >10-30 grams 7 association (p=0.012)
>30-50 grams 8
>50-100 grams 15
>100 grams 30

Potency of steroid Very potent 66 No significant

Potent 13 association (p=0.636)
Moderate 20
Mild 1

Steroid preparation Steroid, antifungal and 52 No significant

antibacterial association (p=0.164)
combination
plain steroids 12
steroid, antifungal 5
combination
Steroid and 10
antibacterial
combination
Steroid, antifungal, 19
antibacterial and
antiprotozoal
combination
Steroid- salicylic acid 2
combination
TABLE 4: Most commonly used preparations in the study population

S Preparatio No Composition Pric

No n of e
pati Rs/g
ent m
s
1 Fourderm 11 Clobetasol + Miconazole +Neomycin + 9.75
Chlorhexidine gluconate
2 Quadrider 8 Beclomethasone+Clotrimazole+ Neomycin 10.5
m RF
3 Dermiford 7 Clobetasol+Gentamicin+Clioquinol+Ketoconazole 5.2
+Tolnaftate
4 Castor NF 7 Clobetasol+Terbinafine+ Ofloxacin+Ornidazole 4.3
5 ClobetaGM 6 Clobetasol+Miconazole+Neomycin 5
6 Betnovate 6 Betamethasone valerate 0.1% potent 1.3
7 Terbinaforc 4 Clobetasol+Terbinafine+ Ofloxacin+Ornidazole 3.4
e plus
8 Dermikem 3 Clobetasol+Terbinafine+ Ofloxacin+Ornidazole 4.6
OC
9 Tigboderm 3 Betamethasonevv+Gentamicin+Tolnaftate+Clioq 4.8
uinol+Chlorocresol
Table 5: ROC, sensitivity and 1-specificity for total steroid amount (gm) and
duration of use of steroid (days)

Variable Area under SE (95% C.I.) p-value b Positive or Sensitivity;

the curve value or (1-Specificity)
Total Steroid 0.744 0.062 (0.623 0.001 32.5 0.963; 0.750
amount (grams) to 0.866)
Duration of use 0.748 0.062 (0.626 0.001 60 0.889; 0.528
(days) to 0.870)
Table 6: A cost comparison of various topical antifungals

PREPARATION Cost range of available brands (Rs/gm)

Terbinafine 4-8
Ketoconazole 4-7
Clotrimazole 2.2-3
Amorolfine 7-10 (broad range 6.5-15.3)
Ciclopirox 5-7
Luliconazole 10-12 (broad range 5.2-16.5)
Figure 1:A and B Striae on abdomen within the lesions of tinea
corporis and in axillae due to prolonged use of clobetasol
containing triple combination creams.
Figure2:Correlation plot between steroid amount and duration
of use among steroid abuse subjects.
Figure 3:ROC curve of the total absolute steroid amount used
for the steroid abuse signs
Figure 4: Altered morphology of tinea on the face following TCS
use; scattered papules and plaques with minimal scaling
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