The Effect of Steroids on Acne
Steroid abuse can cause an especially dangerous, even life-threatening, form of acne known as acne fulminans1. The relationship of acne and steroids is something everyone who uses illicit or prescription steroids needs to know to protect both appearance and basic health.
- Acne and steroids just don’t mix.
- Steroid abuse can trigger a systemic illness called acne fulminans. This form of acne creates gaping holes in the skin and also attack the muscles and joints.
- Dermatologists sometimes offer steroid injections to make pimples less noticeable. These injections can cause lightening and thinning of the skin.
- Steroids are sometimes used to lighten melasma, or brown spots, left after acne heals. Usually the brown spots come back just as soon as the steroid medication is stopped, and continuous use weakens the skin.
- It’s always better to prevent acne than to treat it. Taking care of acne infections at the earliest possible stage can prevent the immune system reaction that causes acne fulminans.
- Prevent acne with a complete acne treatment system such as Exposed Skin Care.
What Is Acne Fulminans?
Sometimes acne suddenly becomes aggressive2. Infections that are normally limited to the surface of the skin suddenly penetrate the lower levels of the skin. The infection breaks down muscle tissue, causing pain and stressing the kidneys as they strain to clear proteins from broken-down tissues from the bloodstream. There can be fever, and weight loss, and destruction of the joints3. Sores on the skin can grow large enough to stick two fingers inside. Antibiotics do nothing to stop the progress of this form of acne known as acne fulminans.
Acne fulminans seems to be induced by hyperactivity of the immune system4. This kind of acne fulminans can be treated with steroids. Other times acne fulminans is actually triggered by excessive use of the steroid testosterone, and is treated by withdrawing steroids. In either case, the condition is manifestation of what is known in medicine as synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO). This form of acne comes on suddenly, literally overnight, causes severe and ulcerating acne, damages muscles and joints5, and usually resolves itself in 4 to 6 weeks. Sometimes the condition causes recurring inflammation in the joints.
What Causes Acne Fulminans?
The precipitating event in acne fulminans is a systemic reaction triggered by the acne bacterium Propionibacterium acnes. The immune system starts generating massive amounts6 of inflammation even affecting tissues and organs where the bacterium is not present, such as the lower levels of the skin, the muscles, and the joints.
Just prior to this change in the immune system, there is usually a fluctuation in testosterone levels7. In teenaged boys, this can the naturally high production of testosterone that occurs during adolescence. In adult men, it is almost always the use of inject testosterone to enhance muscle building. Sometimes acne fulminans occurs after measles, and in at least one case it was triggered by adrenal overactivity.
Acne fulminans is a condition that only occurs in males. Women’s bodies never produce enough testosterone to cause symptoms of this severity, and the small doses of supplemental testosterone some women take to treat loss of interest in sex are not enough to cause acne that is this severe.
Ironically, the treatment for steroid-induced acne is still more steroids9, but steroids such as dexamethasone, prednisolone, and prednisone. These steroids counteract the inflammation10 caused by the body’s over-reaction to acne bacteria trapped under sebum after sebum production was stimulated by testosterone. Weight lifters who continue to use injected testosterone, however, will continue to suffer cycles of the disease until they stop injecting testosterone.
But Are Steroids Always Bad for Acne?
The same steroids used to treat acne fulminans11 are sometimes offered by dermatologists as an “emergency treatment12” for pimples. Both men and women who need to attend a wedding, an anniversary celebration, a graduation, or other event requiring them to look their best often can persuade a dermatologist to inject prednisone or dexamethasone directly into a pimple to reduce redness and irritation. The procedure usually costs about $100 per pimple, not covered by health insurance. Results are immediate and last about a week.
The drawback to this procedure is that repeated injections of steroids into pimples can cause permanent thinning and lightening of the skin. The patch of skin that was prone to blemishes becomes bluish as blood vessels show through the surface. It is more prone to injury, and needs different cosmetic treatment to match the color and matte of the rest of the skin on the face.
Steroids Also Used to Treat Pigmentation Left When Acne Heals
Steroids are also used to treat pigmentation of the skin left when pimples heal13. The most popular prescription for melasma, or brown spots, usually affecting women, is a combination of medications known as Kligman’s formula. This treatment combines 2% hydroquinone (a skin-whitening or -lightening agent), 0.025% tretinoin14 (the non-prescription form of Retin-A used as a lotion), and 1% mometasone (a steroid that is less likely than most to cause thinning of the skin).
The idea behind this treatment was to find an alternative to steroid drugs that only give short-term results in lightening pigmented skin. The hydroquinone in the formula lightens skin. The tretinoin in the formula stimulates the growth of skin and helps hydroquinone penetrate the skin. In this formula, mometasone is added to prevent irritation to the skin rather than as the primary lightening agent.
Doctors offer this combination of medications to both men and women15. The advantage of the combination is that it does not cause irritation that can make pigmentation worse. The disadvantage of this combination is that brown spots tend to come back almost as soon as the medication is stopped, and most patients find a way to get more of the formula to clear up the skin. Using this product for more than 8 to 10 weeks at a time causes all the side effects of any other steroid treatment. And if the product is used by people who have an enzyme deficiency common in people who have Asian skin, the hydroquinone can cause permanent black and blue discoloration of the skin, especially if used on the ears.
Steroids just aren’t a very good treatment for acne. It is a much better idea to stop acne problems before they start, with a complete acne care system like Exposed Skin Care. And if you choose to use prescription testosterone to restore libido or to enhance physical strength, you must pay regular attention to acne prevention to avoid the immune system changes that can trigger acne fulminans.
- Zito PM, Badri T. Acne Fulminans. [Updated 2018 Dec 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan.
- Mehrany K, Kist JM, Weenig RH, Witman PM. Acne fulminans. Int J Dermatol. 2005 Feb;44(2):132-3.
- Ryszard Zaba, MD, PhD; Chief Editor: William D James, MD. Acne Fulminans: Background, Pathophysiology, Frequency. Emedicine.medscape.com. 2019.
- Proença NG. Acne fulminans. An Bras Dermatol. 2017 Sep-Oct;92(5 Suppl 1):8-10. doi: 10.1590/abd1806-4841.20176546.
- Divya BL, Rao PN. SAPHO syndrome with acne fulminans and severe polyosteitis involving axial skeleton. Indian Dermatol Online J. 2016 Sep-Oct;7(5):414-417.
- Alakeel A, Ferneiny M, Auffret N, Bodemer C. Acne Fulminans: Case Series and Review of the Literature. Pediatr Dermatol. 2016 Nov;33(6):e388-e392.
- Saint-Jean M, Frenard C, Le Bras M, Aubin GG, Corvec S, Dréno B. Testosterone-induced acne fulminans in twins with Kallmann’s syndrome. JAAD Case Rep. 2014 Oct 18;1(1):27-9. doi: 10.1016/j.jdcr.2014.10.005.
- Greywal T, Zaenglein AL, Baldwin HE, Bhatia N, Chernoff KA5, Del Rosso JQ, Eichenfield LF7, Levin MH, Leyden JJ, Thiboutot DM, Webster GF, Friedlander SF. Evidence-based recommendations for the management of acne fulminans and its variants. J Am Acad Dermatol. 2017 Jul;77(1):109-117.
- Massa AF, Burmeister L, Bass D, Zouboulis CC. Acne Fulminans: Treatment Experience from 26 Patients. Dermatology. 2017;233(2-3):136-140.
- Lages RB, Bona SH, Silva FV, Gomes AK, Campelo V. Acne fulminans successfully treated with prednisone and dapsone. An Bras Dermatol. 2012 Jul-Aug;87(4):612-4.
- Tanghetti E, Harper J, Baldwin H, Kircik L, Bai Z, Alvandi N. Once-Daily Topical Dapsone Gel, 7.5%: Effective for Acne Vulgaris Regardless of Baseline Lesion Count, With Superior Efficacy in Females. J Drugs Dermatol. 2018 Nov 1;17(11):1192-1198.
- Jaggi Rao, MD, FRCPC; Chief Editor: William D James, MD. 2. What is the role of intralesional steroid injections and comedone removal in the treatment of acne vulgaris? Medscape.com. 2019.
- Sarkar R, Gokhale N, Godse K, Ailawadi P, Arya L, Sarma N, Torsekar RG, Somani VK, Arora P, Majid I, Ravichandran G, Singh M, Aurangabadkar S, Arsiwala S, Sonthalia S, Salim T, Shah S. Medical Management of Melasma: A Review with Consensus Recommendations by Indian Pigmentary Expert Group. Indian J Dermatol. 2017 Nov-Dec;62(6):558-577.
- Leyden J, Stein-Gold L, Weiss J. Why Topical Retinoids Are Mainstay of Therapy for Acne. Dermatol Ther (Heidelb). 7(3):293-304.
- Godse KV. Triple combination of hydroquinone, tretinoin and mometasone furoate with glycolic acid peels in melasma. Indian J Dermatol. 2009 Jan-Mar;54(1):92-3.
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