Medicosnext
Words by Dr Eliz Aryal
She is the Head of the Department of Dermatology at Kathmandu Medical College and Teaching Hospital. A distinguished expert in her field, Dr Aryal has made significant contributions through her numerous published articles on various dermatological topics. Her dedication to advancing ermatological research and patient care is evident in her extensive body of work and leadership within the department.
In today’s world of short-term fame, everyone is either striving to look beautiful or is deeply concerned with their appearance. In this fast-moving era, the younger generation often cannot wait to finish watching a full YouTube video; instead, they prefer to consume TikTok or Instagram reels that are less than a minute long. The nature of beauty products is also evolving to meet the demand for instant glow and perfection. There are many cosmetic products from unregistered companies, where the manufacturer’s details, ingredients, and expiration date are not mentioned at all. The most alarming part is that the language on these products is incomprehensible with products coming in from different countries and labels being in Chinese, Japanese, or Vietnamese, all except for one highlighted English phrase: “MAKE SKIN FAIR” or “GLOW SKIN.” With due respect, our Nepali sisters purchase these products and apply them to their skin. Beyond personal use, they even recommend them to their family and friends, and nowadays, they create blogs and vlogs, make reels, and start counting the comments and likes. So, the concept of beauty all boils down to blogs, instant comments, and likes.
Various preparations claiming to be Chinese herbal medicines are widely available, but there is no governing body regulating their import, distribution or use. In one study analyzing Chinese herbal creams, eight out of 11 creams were found to contain Dexamethasone at a mean concentration of 456 μg/g. All of the patients were unaware of the ingredients in the creams and had assumed they did not contain steroids. Since none of the patients had been advised about potential side effects, they applied the creams to their faces and flexures, often several times a day.
The facial skin is thinner than most other body parts, leading to increased percutaneous absorption of drugs. Additionally, the sebaceous glands on the face are larger, and there is a heightened tendency to sweat, particularly in hot and humid climates. Topical steroids (TS) are easily available on the market at nominal prices as over-the-counter (OTC) products. This accessibility, combined with the pressure to conform to beauty standards and the misuse of various substances, heightens the risk of adverse effects. The frequent and improper application of these products can lead to significant dermatological issues, including skin thinning, irritation, and systemic side effects. Consequently, it is crucial for individuals to be informed about the potential risks and to seek proper medical advice before using such products.
The problem is further compounded by the fact that many people purchase topical steroids from salesmen, who benefit economically from the sales, while patients save on doctor’s consultation fees. At times patients often use topical steroids based on recommendations from friends, neighbors, and relatives, without seeking medical advice. They apply these steroids not only to conditions that do not respond to steroids but also to diseases such as dermatomycoses, which can be exacerbated by steroid use. Ultimately, the greatest (mis)users of topical steroids are individuals caught up in the craze for fairness, often driven by societal pressures and beauty standards. This widespread misuse underscores the urgent need for increased awareness about the potential risks and proper usage of these products to prevent adverse health effects.
When topical steroids are applied unsupervised, they can cause dilation of blood vessels, resulting in erythema (red face). This erythema is further aggravated by steroid-induced dermal atrophy, which thins the skin and reduces support for the underlying vasculature. This leads to chronic immunosuppression, facilitating the overgrowth of microorganisms. These microorganisms can act as superantigens, exacerbating skin issues. Upon withdrawal of the topical steroid, its immunosuppressive effect is removed, leading to a superantigen-induced inflammatory reaction. This reaction is clinically manifested as inflammatory papules and pustules, worsening the skin condition and complicating treatment.
When topical steroids are used, patients often experience a magical response initially, achieving the desired cosmetic effects. However, with continued application, they may begin to develop rashes, and upon discontinuing the drug, a recurrence of rashes, known as the rebound phenomenon, can occur. To avoid this effect, many patients resume using the cream. Eventually, when they find that their skin problems no longer respond to the so-called “magical effect” of the cream, they seek medical consultation. This late consultation often reveals that the persistent skin issues are a result of the adverse effects of prolonged steroid use, necessitating a more comprehensive and informed approach to treatment and skincare.
The primary motivation for starting steroid cream use among these individuals is to achieve a fairer, more beautiful complexion and to address perceived blemishes. In a study conducted in India, the recommendation to use topical steroids came from various sources including friends, relatives, pharmacies, beauty parlors, and even doctors who prescribed them without specific indications. The study revealed that Betamethasone valerate was the most commonly used topical corticosteroid.
Similarly, a study conducted in Nepal showed that most individuals used steroids based on recommendations from friends (38.5%) and chemists (20.5%). The side effects observed included pruritus (38.5%), burning (15.4%), erythema (red face) (74.4%), telangiectasias (66.7%), acneiform eruptions (59%), comedones (35.9%), xerosis (55.1%), photosensitivity (51.3%), and rebound phenomenon (38.5%). These side effects highlight the risks associated with the unsupervised use of topical steroids and underscore the need for better education and regulation regarding their use.
The management of red face in dermatology presents one of the most challenging therapeutic dilemmas for dermatologists. Patients often experience a compromised cutaneous barrier on the face, making them intolerant to many topical treatments. While discontinuing topical steroids is essential for long-term resolution, it commonly leads to a flare-up of symptoms. To manage this, mild topical steroids are applied in a tapering fashion over the course of a week to minimize rebound effects. Alongside this, a high-quality moisturizer is recommended to ensure proper skin hydration, which helps restore the skin barrier and alleviate dryness. Additionally, liberal application of sunscreen is crucial to protect the skin from further irritation and UV damage. This combined approach aims to address the immediate symptoms while supporting the skin’s healing process and preventing future exacerbations. Regular follow-up with the dermatologist is also important to monitor progress and make any necessary adjustments to the treatment plan.
