Demonstration of Steroid Atrophy From Chronic Topical Steroid Use in Various Fitzpatrick Skin Types

Background:

Topical steroids are commonly prescribed first-line medications for various inflammatory and autoimmune dermatologic conditions. Their widespread use raises the importance of proper use. Topical steroids have well-known side effects including skin atrophy, redness, striae, and telangiectasias. These side effects have not been well documented in patients of various skin tones. Primary care clinicians must recognize topical steroid side effects and their appearance in various skin tones. This paper will focus on representing skin atrophy, the most common steroid side effect, in a variety of Fitzpatrick skin types.

Case Presentation:

We present a series of images illustrating skin atrophy after prolonged topical steroid use on various Fitzpatrick skin types. The first case shows Fitzpatrick V skin with areas of erythema, hypopigmentation, and hyperpigmentation on the trunk. The second case presents thin skin with bright erythema and purpuric papules on the upper extremities of Fitzpatrick II skin. A third case showcases symmetric, parallel, linear, maroon dermal scars perpendicular to tension lines in the background of epidermal atrophy circum-anally and on the buttocks of Fitzpatrick IV skin. A fourth case exhibits Fitzpatrick III skin with shiny, thin skin and patches of hypopigmentation and telangiectasias on bilateral cheeks. The fifth case is a Fitzpatrick IV skin type with plaque psoriasis on the lower extremity and a background of skin thinning, hypopigmentation, and visible underlying vasculature from chronic topical steroid use. The final case represents Fitzpatrick VI skin with pyoderma gangrenosum, atrophied skin with overt hypopigmented patches adjacent to a cribriform scar. These cases feature the diverse presentations of skin atrophy on different Fitzpatrick skin types.

Conclusion:

Steroid atrophy is the most common side effect of chronic topical steroid use. Topical steroids are widely used for dermatologic conditions such as atopic dermatitis and plaque psoriasis. Steroids work to quell these inflammatory and autoimmune conditions and are overall tolerated well with proper use. Overuse of topical steroids is common and can cause known side effects of skin atrophy, erythema, striae, and telangiectasias. Recognition of steroid overuse requires knowledge of its presentation in various skin tones. In lighter skin types, atrophy is apparent with visible underlying vasculature and bright red erythema. In darker skin types, atrophy is more subtle and underlying vasculature may appear burgundy or maroon. Awareness of these differences in presentation will allow for quick recognition and immediate cessation of steroid use to prevent further side effects.