Acne from steroids: Symptoms, causes and what you can do

What is steroid acne?

Acne resulting from steroid therapy are named as ‘Steroid acne’. Acne origin from clogged pores leading to inflammation and growth of bacteria in the lipid rich medium this creates.^[1] This process is mediated by 4 major mechanisms;

1. Seborrhea – excessive production of lipid substance (sebum) from sebaceous glands at the hair follicles
2. Excessive keratin deposition in hair follicles
3. Overgrowth of natural skin bacterium C acnes
4. Inflammatory reaction

Steroids, either topically applied or systemically used, can enhance this process of acne formation. Typically, steroid acne appears as dome shaped small skin colored or red papules of 1 to 3 mm in size, and they are scattered across the face, upper trunk, and upper arms.^[2]

Small, red bumps near the nose caused by steroid acne, often appearing in clusters that look similar

What causes steroid acne?

Steroids are widely used synthetic hormone medication with anti-inflammatory and immunosuppressive properties. Therefore, it is used to treat several different health conditions including Cushing syndrome, asthma, allergy, dermatitis and blood cancers like leukemia.^[3] One of the well-known side effects of steroids are the steroid acne.

There are different formulations of steroids that can give rise to steroid acne. There are locally applicable steroid creams people tend to misuse as a skin lightening agent. Other systemic steroids include tablets, injectables, inhaled corticosteroids and per rectal preparations.^[3] Furthermore, athletes and body builders who use androgenic anabolic steroids are prone to get steroid induced acne.

Several hormones in the body, including steroids and androgens, have the ability to bind with receptors in the oil producing glands (sebaceous glands) in the skin that open into hair follicles. This causes excessive growth of sebaceous glands and excessive sebum production, leading to clogged follicles and creating the perfect environment for a bacteria called Cutibacterium acnes to grow.^[1]

Acne Vulgaris

What does steroid acne look like?

Steroid acne is mostly similar to regular acne, where multiple red/ pus filled bumps appear on the skin. They mostly involve chest, back and the arms, while inhaled corticosteroids used in conditions like wheezing may give rise to acne around the nose and the mouth. The characteristic feature to identify steroid acne is the similar appearance (monomorphic appearance) of all the bumps present.^[4] They are symmetrically distributed, and the skin involved may look red and inflamed. Usually, the lesions appear quickly after starting the steroids (within 2-5 days) and clear out soon after stopping the medication.^[4]

Red Bumps Spread Across Her Chest and Neck — Even the Cream Couldn’t Help

Red bumps spreading across the chest after using a topical steroid cream (triamcinolone) — a typical sign of steroid-induced acne

Question

have had small red bumps forming on my chest, neck, and face area for the past two weeks. I have tried using some previously prescribed triamcinolone for this, but the rash has not been reduced by daily use of this product. I think it is actually spreading. On my neck, the bumps hurt to touch.

Dermatologist’s answer

Based on the information and images of your face and chest, this is possibly STEROID ACNE: This is an acne eruption caused by, or aggravated by, steroids. It’s more or less impossible to tell what elicited the skin problem at the beginning but when started applying a potent steroid as triamcinolone you initially get better. But in the long run you relapse every time when stopping the treatment. Of course, you then treat once more, and you end up in a kind of vicious circle where the steroid maintains your skin problems. The treatment plan is to stop applying any topical steroid! You will get a flare up and to cope with this you need additional treatment with some anti-inflammatory oral medicine like tetracycline (prescription needed). I strongly recommend that you see your family physician or a dermatologist in person.

Steroid Acne vs Common Acne

Could it be fungal acne (Malassezia folliculitis)?

Malassezia folliculitis is a skin condition that closely resembles both steroid acne and acne vulgaris. It is easy to confuse this condition with steroid acne as it also presents with skin lesions of same size, uniform appearance (monomorphic lesions) and the absence of comedones.^[5] However, fungal acne are itchy, and the treatment is completely different from that of steroid acne, so the correct identification is of utmost importance. They result from overgrowth of skin commensal fungi Pityriasis versicolor and Malassezia.^[5] A dramatic improvement is achieved from antifungal treatment, especially with oral antifungal tablets.^[5]

See images of common itchy rashes and how to tell them apart »

Real-life case: when steroid creams make it worse

She Thought the Cream Would Calm the Rash. Two Weeks Later, It Got Worse

Red, itchy bumps spreading across the chest after two weeks of using a topical steroid cream — a pattern consistent with steroid-induced acne or Malassezia folliculitis

Question

I am a 28-year-old female. I went to doctor’s office two weeks ago when I noticed a red, burning in the area on my chest. I was given topical steroid cream to use twice daily. On day 14, red itchy and burning bumps had appeared overnight. Stopped cream but bumps continue to spread across the chest.

Dermatologist’s answer

Based on the information and images of your chest, this is possibly steroid Acne: Steroid acne has almost the same symptoms as typical acne. But with steroid acne, steroid creams use is what makes the oil (sebaceous) glands susceptible to inflammation and infection. Discontinuing the corticosteroid treatment is the first step in managing the acne. I suggest applying topical benzoyl peroxide, twice daily. It is available over the counter at any pharmacy. If there is no improvement within a month, I recommend that you see a dermatologist in-person for a closer inspection of your skin, in order to receive adequate treatment that might require a prescription. For example, oral treatment with an antibiotic (e.g. Doxycycline) plus a topical treatment with benzoyl peroxide combined with adapalene (Epiduo gel).

How to treat steroid acne

The management starts with the discontinuation of all the non-essential steroid medication. Understanding the nature of acne, setting realistic treatment goals and sticking to a proper skin care routine are essential basic steps in acne management. The medications used to treat steroid acne are similar to those used to treat acne vulgaris. Treatment should be carried out for at least 2-3 months to get results.^[1] However, the time taken to heal will differ from person to person.

1. Over the counter medication in mild cases

Mild acne consisting of just a few comedones or papules without scarring, can be treated with topical creams. Over the counter medications like topical retinoids, benzoyl peroxide and salicylic acid can help with the acne.^[1]

2. Prescription medication for moderate-severe cases

Moderate to severe acne are a more serious issue that warrants a doctor visit and prescription medication. Some of the treatment options your doctor may prescribe are;

• Topical antibiotic gel preparations (e.g. Clindamycin, erythromycin)
• Oral antibiotic tablets (e.g. Tetracyclines)
• Oral antifungals if fungal infection is suspected
• Isotretinoin tablets
• Hormonal therapies including oral contraceptives and spironolactone

3. Other treatment options

Other options include phototherapy, where the affected skin is exposed to a blue light.

Can steroid acne be prevented?

Most of the time steroid acne occur because of unsupervised and un-anabolic prescribed steroid use. Refraining from using steroid creams as whitening agents and agents for body building may save you from annoying acne breakouts. Furthermore, good skin hygiene, use of non-comedogenic and non-irritant mild cosmetics will help you keep steroid acne bay. A topical retinoid may help keep pores clear if you need to use steroids for medical reasons.

While skincare can support prevention, it’s also worth noting that overall lifestyle factors like diet and supplement use may influence acne development. Explore how supplements can help with acne prevention

When to get a skin review

If the acne is severe and causing you significant distress, you should consider a visit to your healthcare provider. Widespread acne that does not heal when you stop the steroid medication, or those that show no response to over-the-counter treatment also warrant proper medical attention. Furthermore, if the acne looks serious, with pus filled swollen red bumps that appear infected, it needs more vigorous treatment than over the counter medication. It is extremely important to consult your dermatologist in such instances, in order to confirm the diagnosis and start specific treatment early, thereby avoiding scarring and disfiguration of your skin.

The takeaway

Steroid acne is a type of acne triggered by topical or systemic steroid use. It appears suddenly as small, uniform red or pus-filled bumps, mainly on the chest, back, and arms. Early recognition and proper treatment, including discontinuing unsupervised steroid products, can prevent long-term skin damage. Avoid self-medicating with steroid creams and use non-comedogenic skincare products. And do not hesitate to consult a doctor early if you suspect steroid acne.