topical steroids (was Re: derm/doctor in any bay area of San Francisco)

[Guest guest]

, I understand emotionally why you were upset, having read

stories here in this group.

But many dermatologists use topicals steroids responsibly in rosacea

care, in at least two clinical scenarios: first, while antibiotic

treatment is being instituted, to provide an immediate response and

decrease inflammation as the antibiotics level in the skin rises to

therapeutic levels (takes up to six weeks, not 3-4 days). Second,

topical steroids are used in chronic care, intermittently (not

continuously), to manage more severe rosacea, as some members in this

group described several months ago.

It's a risk/benefit thing, and intelligent use of steroids will

decrease the risks while increasing benefits. But as you say, there

are risks of skin thinning and other changes even in the best of

circumstances, when used chronically and continuously. Also, one side

effect that may develop in the short term, even a few days, is

worsening acne. This is commonly called steroid-induced rosacea but

it's not rosacea, it's a side effect of topical steroids that can

effect anyone. Theoretically this acne resolves completely when the

steroids are stopped, but that's not always the case.

Desowan is the mildest form of topical steroids, in type and

concentration. No question it is effective, and by decreasing

inflammation it increases the effectiveness of antibiotic topicals

such as Noracet (which I believe is similiar to Plexion, both

commonly prescribed for rosacea and/or acne vulgaris) or the metros

the early days of treatment, until adequate antibiotic skin levels

are maintained.

I can't explain why your dermatologist was reluctant to discuss the

pros and cons of using topical steroids with you. Your questions

sound reasonable to me, and expressing a reluctance to begin topical

steroid therapy may be overdramatic but not wholly unreasonable.

There are doctors who believe rosaceans should avoid all topical

steroid use (not so much from the above risks, but because the risk

of rebound inflammation after tapering may be more difficult to

manage than the original inflammation, so those who don't respond as

expected to antibiotics may be in a worse position than when they

started).

But I disagree with you that simply prescribing steroids is an

indication that the dermatologist is not responsible. Keep in mind

that the majority of rosaceans who used topical steroids do so with

success, esp when used under a good dermatologist's care.

Another thing to keep in mind: those with trivial or mild rosacea do

not always require a dermatologist's care if their rosacea is

reasonably managed with only attention to triggers and by OTC

products. With the exception of topical antibiotics, medical care is

directed at those with moderate rosacea or worse, and with increased

efficacy carries with it increased risk of side effects. Medical

doctors provide advanced care for conditions like rosacea; it's a

common assumption among doctors that reasonably intelligent patients

don't need physicians to educate them on OTC products and general

skin care. From my perspective, things have changed over the past few

generations, and now people routinely visit doctors at the very first

sign of disease, have extremely high expectations for every

encounter, and expect instructions on basic health care and consumer

purchasing. Whether appropriate or not, I think that's reality today

for many patient populations.

Also, some people believe that if a little is effective then more is

better -- a recent poster asks whether he should increase his

antibiotic dose because it seems to be working. But dosages beyond

the optimized tend to increase the risks of side effects over

benefits. Others believe that if a treatment works for moderate

rosacea then it should really be effective for mild rosacea, but

that's not true either. For example, side effects such as drying

become trival when compared to moderate-severe rosacea, but that may

not be the case if the rosacea is much milder.

Have you considered a dermatology clinic within UCSF? I know some on

the board have had mixed experiences with them, but academic

physicians are a good source of care if your rosacea is difficult to

manage.

I appreciate the opportunity to address your concerns publicly rather

than in private email. Best of luck, .

Marjorie

Marjorie Lazoff, MD

> Hello again,

> Now I'm in search of a decent derm. So far I haven't had a good

> experience. The last derm I saw wanted to perscribe Desowan

lotion.

> It angered me that a steroid is still being perscribed and nor was

> it going to be for the short-term (2 or 3 days) but more like 6

> weeks when I was due for the next appointment.

>

> Can anyone help.

> Thanks in advance.

> mary

[Guest guest]

, I understand emotionally why you were upset, having read

stories here in this group.

But many dermatologists use topicals steroids responsibly in rosacea

care, in at least two clinical scenarios: first, while antibiotic

treatment is being instituted, to provide an immediate response and

decrease inflammation as the antibiotics level in the skin rises to

therapeutic levels (takes up to six weeks, not 3-4 days). Second,

topical steroids are used in chronic care, intermittently (not

continuously), to manage more severe rosacea, as some members in this

group described several months ago.

It's a risk/benefit thing, and intelligent use of steroids will

decrease the risks while increasing benefits. But as you say, there

are risks of skin thinning and other changes even in the best of

circumstances, when used chronically and continuously. Also, one side

effect that may develop in the short term, even a few days, is

worsening acne. This is commonly called steroid-induced rosacea but

it's not rosacea, it's a side effect of topical steroids that can

effect anyone. Theoretically this acne resolves completely when the

steroids are stopped, but that's not always the case.

Desowan is the mildest form of topical steroids, in type and

concentration. No question it is effective, and by decreasing

inflammation it increases the effectiveness of antibiotic topicals

such as Noracet (which I believe is similiar to Plexion, both

commonly prescribed for rosacea and/or acne vulgaris) or the metros

the early days of treatment, until adequate antibiotic skin levels

are maintained.

I can't explain why your dermatologist was reluctant to discuss the

pros and cons of using topical steroids with you. Your questions

sound reasonable to me, and expressing a reluctance to begin topical

steroid therapy may be overdramatic but not wholly unreasonable.

There are doctors who believe rosaceans should avoid all topical

steroid use (not so much from the above risks, but because the risk

of rebound inflammation after tapering may be more difficult to

manage than the original inflammation, so those who don't respond as

expected to antibiotics may be in a worse position than when they

started).

But I disagree with you that simply prescribing steroids is an

indication that the dermatologist is not responsible. Keep in mind

that the majority of rosaceans who used topical steroids do so with

success, esp when used under a good dermatologist's care.

Another thing to keep in mind: those with trivial or mild rosacea do

not always require a dermatologist's care if their rosacea is

reasonably managed with only attention to triggers and by OTC

products. With the exception of topical antibiotics, medical care is

directed at those with moderate rosacea or worse, and with increased

efficacy carries with it increased risk of side effects. Medical

doctors provide advanced care for conditions like rosacea; it's a

common assumption among doctors that reasonably intelligent patients

don't need physicians to educate them on OTC products and general

skin care. From my perspective, things have changed over the past few

generations, and now people routinely visit doctors at the very first

sign of disease, have extremely high expectations for every

encounter, and expect instructions on basic health care and consumer

purchasing. Whether appropriate or not, I think that's reality today

for many patient populations.

Also, some people believe that if a little is effective then more is

better -- a recent poster asks whether he should increase his

antibiotic dose because it seems to be working. But dosages beyond

the optimized tend to increase the risks of side effects over

benefits. Others believe that if a treatment works for moderate

rosacea then it should really be effective for mild rosacea, but

that's not true either. For example, side effects such as drying

become trival when compared to moderate-severe rosacea, but that may

not be the case if the rosacea is much milder.

Have you considered a dermatology clinic within UCSF? I know some on

the board have had mixed experiences with them, but academic

physicians are a good source of care if your rosacea is difficult to

manage.

I appreciate the opportunity to address your concerns publicly rather

than in private email. Best of luck, .

Marjorie

Marjorie Lazoff, MD

> Hello again,

> Now I'm in search of a decent derm. So far I haven't had a good

> experience. The last derm I saw wanted to perscribe Desowan

lotion.

> It angered me that a steroid is still being perscribed and nor was

> it going to be for the short-term (2 or 3 days) but more like 6

> weeks when I was due for the next appointment.

>

> Can anyone help.

> Thanks in advance.

> mary