Tagged Steroids

Your ‘Maskne’ Might Not Be Acne at All

Perioral dermatitis, a complex facial rash that is often mistaken for acne, is becoming more common, some experts say. Here’s how to spot, treat and prevent this irritating condition.

It started as a mini constellation of red dots near the right corner of my lips. Probably just “maskne,” I figured. I slathered on some acne cream and tried to forget about it.

But the inflamed, rashy spots didn’t fade away. In fact, they grew larger, spawning dandruff-like scales and flakes. Within days, the red dots had spread to the left side of my mouth, and even — to my horror — sprinkled across my eyelids. When I opened my mouth, I felt the raw, burning skin at the corners crack.

After a telemedicine visit with my dermatologist, I learned that I had perioral dermatitis — a noncontagious facial rash that often shows up as clusters of tiny, scaly, red, uncomfortable bumps above irritated skin. “We see it mainly around the mouth,” said Dr. Anna Chien, a dermatologist at the Johns Hopkins University School of Medicine. “Some people can have similar breakouts around the eyes.”

Cases have become more common since the coronavirus outbreak began, some experts say. In one Canadian survey of 77 dermatologists published in September, more than a third reported either a large or slight increase in perioral dermatitis instances since the beginning of the pandemic.

“In our clinic,” Dr. Chien said, “we are seeing many more perioral dermatitis and other rashes related to masks.” Dr. Jessica Sprague, a dermatologist at the U.C. San Diego School of Medicine, noted a similar phenomenon. “Masks alter the skin environment, and they can also cause a lot of skin irritation,” she said, adding, “I’m definitely seeing it more now in the setting of mask wearing.”

What causes it

Perioral dermatitis might look a lot like acne, but the resemblance is deceptive, said Dr. Carrie Kovarik, a dermatologist at the Hospital of the University of Pennsylvania and a member of the American Academy of Dermatology’s Covid-19 task force. “People confuse it with ‘maskne,’ and they are two different things.”

With mask-induced acne, your pores get clogged with dirt, skin flakes or oil, giving rise to inflamed cysts that may burst. But perioral dermatitis is more of an inflammatory rash. There can be various causes, but it tends to be triggered by a disruption of your skin’s natural equilibrium, Dr. Sprague said, from the use of topical substances like steroid medications or irritating cosmetics.

The humid, enclosed space behind a mask may also encourage perioral dermatitis rashes to form. “Depending on what kind of mask you’re wearing, you could really have a lot of moisture sitting there on your face,” Dr. Kovarik said. “You’re almost creating this skin fold-type area,” a little like the damp crevices that can form between rolls of skin.

That can modify the face’s natural microbial balance, research suggests, contributing to perioral dermatitis and related conditions. “When you wear a mask, you’re basically changing the terrain,” said Dr. Whitney Bowe, a dermatologist based in New York.

This can encourage or discourage the growth of certain microbes, like bacteria and yeast, which may be involved in perioral dermatitis, and can touch off “this cycle of making the disease even worse,” Dr. Kovarik said.

The rash appears most often in adult women, but can also crop up, albeit less frequently, in young children. Unlike cold sores, perioral dermatitis bumps are not thought to be caused by a specific virus and usually do not migrate onto the lips themselves.

How to prevent and treat it

Since perioral dermatitis is so complex, it can be challenging to treat and may take a long time to clear, Dr. Sprague said. But if you monitor your skin closely and follow some simple rules, you might be able to steer clear of the condition completely or nip it in the bud.

Practice good mask hygiene. Masks are currently a public health necessity, but cleaning them regularly may help keep perioral dermatitis at bay.

As soon as you are home and can safely remove your mask, wash your face with a gentle, fragrance-free cleanser, Dr. Sprague said. When it’s time to don your mask again, resist the temptation to use one that is dirty, since it can disrupt your face’s microbial balance. “It’s like underwear,” Dr. Bowe said. “You wouldn’t wear your underwear two days in a row.”

Avoid steroid-based skin creams. Many people use steroidal anti-inflammatory medications, like hydrocortisone cream, to manage symptoms of perioral dermatitis, Dr. Chien said, but while such medications may clear redness temporarily, a rebound rash is likely to appear once you stop using them. “It’s very reasonable to think, put on some steroids, but that tends to make it worse,” she said. “The minute you stop, it comes back with a vengeance.”

Researchers don’t completely understand why this happens, but some think that steroid creams might allow bacteria to overgrow by suppressing the body’s local immune response.

If you have allergies or asthma, think about switching your meds. As with steroid creams, Dr. Sprague said, inhaled or spray steroidal medications commonly used to treat allergies or asthma — like Flonase, Nasacort or Symbicort — are thought to trigger perioral dermatitis, perhaps because they modify the body’s immune response.

If you use any of these medications and are worried about perioral dermatitis, talk with your doctor about your treatment plan. Some allergy or asthma sufferers may need to remain on steroid medications, Dr. Sprague said. However, others may be able to consider other nonsteroidal drugs, like cetirizine (Zyrtec), which are not thought to cause perioral dermatitis.

Streamline your skin-care products. Using too many skin care products can throw off your skin’s natural balance, according to Dr. Bowe, increasing the risk of an outbreak. In one study of 232 people in Australia, those who used foundation, night cream and moisturizer were 13 times more likely to develop perioral dermatitis than those who used moisturizer alone.

Similarly, if you’re managing a flare, minimalism is key. “The best thing you can do is baby your skin,” Dr. Sprague said. “Stop any thick cosmetics, serums, etc.”

Dr. Jennifer Holman, a dermatologist in Tyler, Texas, recommended washing your face twice a day with a gentle cleanser, such as a sulfur face wash, and following up with a fragrance-free moisturizing lotion. It’s OK to use a little mineral makeup, she added, because it doesn’t tend to aggravate the rash.

Don’t dabble in unproven treatments — see your dermatologist. Plenty of alternative treatments for perioral dermatitis are available on the web, from swabbing the skin with apple cider vinegar to taking supplements of certain herbs, like neem. But those haven’t been scientifically proven to work, Dr. Holman said. And since the rash is notorious for sticking around, it’s important to seek professional help.

Dr. Sprague said she’ll often start by prescribing a topical antibiotic, like metronidazole — not to banish an infection per se, but to reduce the inflammation and give the skin a chance to heal. Pimecrolimus, a nonsteroidal anti-inflammatory cream that is commonly used to treat rosacea and eczema, can also help clear up the rash.

When these treatments fall short, Dr. Sprague said she’ll sometimes recommend a several-week course of an oral antibiotic, like doxycycline, which can also help to reduce inflammation.

Perioral dermatitis “seems like something minor, but you can really get into difficult situations” where the rash persists, Dr. Kovarik said. “You want someone who’s familiar with treating this.”

My own perioral dermatitis has improved since I started treating it with a topical antibiotic and a gentle, fragrance-free lotion, but it hasn’t yet vanished. I still have some tiny bumps around my mouth and eyes, so I’m leveling up with a monthlong course of oral doxycycline. I hope it will restore my clear skin — and I look forward to a post-pandemic future when I can let my face breathe freely once again.

Elizabeth Svoboda is a science writer in San Jose, Calif., and the author of “What Makes a Hero?: The Surprising Science of Selflessness.”

The Risks of Using Steroids for Respiratory Infections

Personal Health

The Risks of Using Steroids for Respiratory Infections

Doctors often prescribe them for sore throats and the common cold, even though evidence of benefit is sorely lacking.

Credit…Gracia Lam
Jane E. Brody

  • Dec. 28, 2020, 5:00 a.m. ET

“Steroid Shots and the Culture of Instant Gratification,” an editorial published Oct. 8 in JAMA Otolaryngology-Head & Neck Surgery online, highlights a chronic ailment in American medical care: a frequent failure to practice evidence-based medicine. Maybe I’ve been living under a rock, but I was surprised to learn that doctors often prescribe oral or injected corticosteroids for acute respiratory tract infections like sore throat, sinusitis, bronchitis and the common cold even though evidence of benefit is sorely lacking and risks of the drugs are widely known.

Yet a recent analysis of nearly 10 million outpatient medical visits in the United States showed that nearly 12 percent of patients with acute respiratory infections were prescribed oral or injected steroids, and this dubious practice is on the rise. The analysis found that prescriptions for steroids like prednisone to treat acute respiratory ailments nearly doubled from 2007 to 2016.

Although steroids can be invaluable, even lifesaving, medications often vital to treating asthma, autoimmune conditions, and chronic pulmonary disease and preventing transplant rejection, their misuse can result in a treatment that is worse than the disease.

The editorial writer, Dr. Edward D. McCoul, otolaryngologist at the Ochsner Clinic Foundation, described a scenario that is apparently replicated hundreds of thousands of times a year in the United States among patients given steroid injections for acute respiratory infections: “Within moments of receiving the intramuscular injection your congestion wanes, the headache vanishes, and your energy level skyrockets.”

Sure, Dr. McCoul told me, you feel better, at least temporarily — steroids, after all, counter inflammation and have a euphoric, energizing effect. But at what price?

The answer to that question is addressed in another commentary published in the Annals of Internal Medicine. Dr. Beth I. Wallace at Michigan Medicine and Dr. Akbar K. Waljee of the V.A. Ann Arbor Healthcare System listed three serious risks that can follow as few as three days of treatment with corticosteroids taken orally even by relatively young, otherwise healthy patients: gastrointestinal bleeding, sepsis and heart failure.

A Danish study found an elevated risk of diabetes and osteoporosis among patients who had received one or more steroid shots a year for three or more years to treat allergic rhinitis, another use of steroids lacking evidence of benefit.

Dr. Evan L. Dvorin, internist at the Ochsner Health System and Dr. Mark H. Ebell of the University of Georgia, writing in the journal American Family Physician, added several other frightening side effects linked to the brief use of steroids: low blood sugar, elevated blood pressure, mood and sleep disturbances, fracture and blood clots.

Dr. Wallace, a rheumatologist whose patients often depend on long-term steroid therapy, said with regard to short bursts of steroids for respiratory infections, “A very large number of young, otherwise healthy patients are receiving a treatment that we know can be harmful for a condition where steroids just aren’t indicated.”

In an interview, Dr. Dvorin said that although steroids may make people euphoric, they can also “make some people feel pretty bad by causing anxiety, jitteriness and manic-like behavior.” In people with pre-existing psychosis, short-term steroid shots can trigger a psychotic episode, Dr. McCoul said.

Drs. Dvorin and Ebell wrote, “Physicians might assume that short-term steroids are harmless and free from the widely known long-term effects of steroids. However, even short courses of systemic corticosteroids are associated with many possible adverse effects.” (“Systemic” refers to both oral and injected steroids, as opposed to topical uses on the skin.)

Furthermore, there is no credible evidence to justify such risks when treating a condition like a cold or sinus infection, the Michigan doctors noted. When any treatment is prescribed, it’s the practitioner’s job to first weigh its expected benefits against possible risks. However, Drs. Wallace and Waljee reported that “corticosteroid bursts are frequently prescribed for self-limited conditions, where evidence of benefit is lacking.” Leading the list of such inappropriate uses of steroids are acute respiratory tract infections that usually resolve without specific treatment within a week or two.

As with antibiotics and opiates, short-term use of injected or oral steroids have “well-defined indications but can cause net harm when used — as they frequently are — when evidence of benefit is low,” they concluded.

In Louisiana, where Dr. McCoul practices, steroid shots for upper respiratory infections are shockingly common, he said. “Patients may go to urgent care five or six times a year to get a steroid shot.” Although the drugs themselves are not addictive, getting these shots “is like a behavioral addiction,” he said.

“It’s a pervasive practice for which there’s practically zero evidence of benefit,” Dr. McCoul added. “It’s important for the public to understand that most upper respiratory infections are self-limited; no intervention is required. They resolve on their own if you don’t seek care.”

However, when patients do go to the doctor, they expect something to happen, and doctors are often happy to oblige. They are reimbursed by insurance if they administer an injection but not if they hand patients a prescription for oral steroids.

A single steroid shot provides the equivalent of six days of oral prednisone at 20 milligrams a day, Dr. Dvorin said. But unlike pills that patients can stop taking, once an injection is administered, the drug can’t be removed from the body if it causes an adverse effect or confers no benefit.

Asked how to avoid inappropriate use of steroids, Dr. Dvorin suggested that patients look providers in the eye and ask, “Is this evidence-based? Is it something that’s really going to help me? What are the possible side effects? Are steroids really needed? What else can I do or take to relieve my symptoms?”

Less hazardous options abound, Dr. Wallace said. They include over-the-counter drugs like ibuprofen, acetaminophen (Tylenol and its store brands), and a nighttime cough syrup. Dr. McCoul suggested using an over-the-counter decongestant to reduce mucus production and relieve pressure in the head. Alternatively, try a saline nasal spray, which he said is “one of the best things a person can do for any acute or chronic upper respiratory condition in which inflammation plays a role.”

You can purchase a salt mixture or make your own to use in a nasal irrigation device like a Neti pot. Mix 3 teaspoons of noniodized salt with 1 teaspoon of baking soda. Add 1 teaspoon of the mixture to 8 ounces of distilled (or boiled and cooled) water in the device. Tilt your head over the sink at a 45-degree angle, place the spout in one nostril and gently pour in the salt solution. Repeat in the other nostril.

Attention, Teenagers: Nobody Really Looks Like That


Credit Anna Parini

The universal truth of puberty and adolescence is body change, and relatively rapid body change. Teenagers have to cope with all kinds of comparisons, with their peers, with the childhood bodies they leave behind, and with the altered images used in advertising and in the self-advertising on social media.

It may be that the rapid way the body changes during these years can help adolescents believe in other kinds of change, including the false promises that various products can significantly modify their size and shape. A study published last month in the journal Pediatrics looked at two kinds of risky behavior that are increasingly common over adolescence: the use of laxatives for weight loss and the use of muscle-building products.

It used data from an ongoing study of more than 13,000 American children, the Growing Up Today Study (GUTS). The participants’ mothers took part in the Nurses’ Health Study II, and the children were recruited in 1996, when they were 9 to 14 years old, and surveyed about a variety of topics as they grew up.

By age 23 to 25, 10.5 percent of the women in this large sample reported using laxatives in the past year to lose weight; the practice increased over adolescence in the girls, but was virtually absent among the boys. Conversely, by young adulthood, about 12 percent of the men reported use of a muscle-building product in the past year, and again, this increased during adolescence.

So a lot of young women are taking laxatives to try to become very thin, and a lot of young men are using products to help them bulk up and become more muscular. The researchers were interested in how these practices were associated with traditional ideas of masculinity and femininity. They found that, regardless of sexual orientation, kids who described themselves as more gender conforming were more likely to use laxatives (the girls) or muscle-building products (the boys).

“The link is the perception that they are going to alter your weight, shape, appearance,” said Rachel Rodgers, a counseling psychology researcher who studies body image and eating concerns and is an associate professor of applied psychology at Northeastern University.

“The representations of ideal appearance in society are very restrictive and very unrealistic both for men and for women,” she said. “They portray bodies that are unattainable by healthy means.”

Jerel Calzo, a developmental psychologist who is an assistant professor at Harvard Medical School, and the lead author on the study, said that one important aspect of this research was the way it highlighted the vulnerability of those who identify with traditional gender ideals.

“Usually in research we tend to focus on youth who are nonconforming, who we might focus on as more at risk for negative health outcomes, depression, who might be ostracized or victimized,” he said. But there are risks as well for those who are trying to measure up to what they see as the conventional standard.

The GUTS participants were asked to describe themselves as children in terms of the games they liked and the movie and TV characters they imitated, and this was used to score them as more or less “gender conforming.”

The early patterns of gender conformity were significant, Dr. Calzo said, because they were linked to behaviors that lasted through adolescence and into young adulthood. “Laxative use increases with age, muscle-building product use increases with age,” he said. “There is a need for early intervention.”

Chronic use of laxatives can affect the motility of the bowel so that it can be hard to do without them, and overdoses can alter the body’s balance of electrolytes, to a really dangerous extent.

“There’s a lot of shame and guilt for laxative abuse,” said Sara Forman, an adolescent medicine specialist who is the director of the outpatient eating disorders program at Boston Children’s Hospital. And many products marketed as cleanses or herbal teas are not labeled as laxatives, though they contain strong laxative ingredients.

The muscle-building products in the study included steroids, creatine and several others. The risks of steroids are well known, from hormonal imbalances and shrinking testicles to acne and aggression. With other commercial muscle-building products, the risks may have more to do with the lack of regulation, Dr. Calzo said. The products can contain banned substances or analogues of banned substances, like the amphetamine analogue found in popular diet and workout supplements last year.

And of course, the muscle-building products won’t reshape you into the photoshopped model any more than the laxatives will.

As Dr. Calzo says, we need to worry about the vulnerabilities of children who are growing up with issues of gender identity and sexuality. But don’t assume that more “mainstream” or “conforming” kids have it easy when it comes to body image. Parents can help by keeping the lines of communication open and starting these conversations when children are young. We should be talking about the images that our children see, about how real people look and how images are altered.

And that conversation should extend to social media as well; in a review by Dr. Rodgers, increased social media use was correlated with body image worries. “Teenagers are looking at their friends on social media and seeing photos that have been modified and viewing them as something real.”

The other message for parents is about helping to model healthy eating, family meals, realistic moderation around eating and exercising, and to refrain from any kind of negative comments or teasing about a child’s body. “Research has shown people who have more body satisfaction actually take care of themselves better, which suggests that the approach of making them feel bad is actually not helpful,” Dr. Rodgers said.

Every adolescent, across gender, gender identity, gender conformity, and sexuality, lives with a changing body and the need to navigate body image and identity. There are a lot of unrealistic images out there to measure yourself against, and a lot of false promises about how you might get there.


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