Corticosteroids are commonly prescribed by practitioners in many medical specialties for the treatment of chronic inflammatory conditions. The use of corticosteroids in the treatment of chronic rhinosinusitis is well described and based on their anti-inflammatory effects. The duration of corticosteroid therapy in these conditions is often less than 1 month, in contrast to the treatment of chronic respiratory diseases (ie, asthma, chronic obstructive pulmonary disease) or autoimmune disorders (ie, rheumatoid arthritis, systemic lupus erythematosus, Crohn disease, and ulcerative colitis), which can last for years.
Cutaneous complications caused by corticosteroids include Cushing syndrome, skin atrophy, striae, ecchymoses, and changes in mechanical properties of the skin. Less commonly, pustular acne, tinea incognito, and Stevens-Johnson syndrome may occur. 24 Corticosteroids cause a reduction in mitotic activity of the keratinocytes in
the germinal layer and flattening of the rete ridges. They may also cause a loss of ground substance and reduction of fibroblast size. These changes ultimately cause thinning of the dermis and increase the fragility of the skin. In some cases, a steroid effect on microvascular endothelial cell development causes telangiectasia formation, whereas the loss of ground substance decreases the structural support for vessels and increases their dilation, leading to ecchymosis. Atrophy and ecchymoses are often reversible on the discontinuation of corticosteroids, but striae are not. Striae are visible linear scars that occur as a result of inflammation and edema of the dermis. Collagen and elastin are then deposited along these lines of mechanical stress, causing scar tissue formation. The frequency with which these complications occur is not entirely understood; however, they seem to be more common with systemic corticosteroids than topical or inhaled corticosteroids. One study demonstrated cutaneous changes in 37 of 80 (46%) patients on a mean dose of 31 mg of prednisone over 3 months. These changes included hirsutism, spontaneous bruising, and altered wound healing. Of the patients with hirsutism, all were female, and the risk tended to increase with age. 35 A second study demonstrated almost a 5-fold increase in ecchymoses with corticosteroid use; another study found a 4-fold increase in the frequency of Cushing syndrome, acne, and hirsutism.