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Did you know that topical steroids can cause thinning of the skin, especially if they are used incorrectly on areas that are already thin to begin with?
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My guest today, Hadar Lev-Tov, MD, MAS, is an Assistant Professor, and the Director of the Wound Healing Fellowship Program at the University of Miami, Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, the Miller School of Medicine.
Dr. Lev-Tov completed his residency at Albert Einstein College of Medicine and obtained a Master degree in clinical research from the University of California, Davis.
His research interests include the treatment and prevention of chronic wounds, such as venous leg ulcers and diabetic foot ulcers as well as hidradenitis suppurativa.
Dr. Lev-Tov's work is supported in part by the Dermatology Foundation, NIH and industry. He is also the co-host of the popular Learnskin Podcast. He specifically enjoys bringing an integrative approach to each of his patients.
Join us as we talk about how topical steroid creams can cause thin skin.
Have you experienced thin skin from using topical steroids? Tell me about it in the comments!
In this episode:
- Nutrients needed to boost collagen production
- Lifestyle factors that block or decrease collagen production
- Why does the skin get thin with topical steroid cream use?
- Is it possible to reverse thin skin caused by topical steroid creams?
- How can you protect your skin if it is thin?
Quotes
“Topical corticosteroids and systemic corticosteroids have an effect on the skin causing thinning of the top layer of the skin called the epidermis.” [4:19]
“When you start applying it to skin that's already thin to begin with, like on your face or on the genitalia, this is where very quickly you can get into trouble.” [5:08]
Links
Healthy Skin Show ep. 152: Hidradenitis Suppurativa: An Integrative Approach w/ Dr. Hadar Lev-Tov
Follow Dr. Lev-Tov on Instagram
Is Collagen Good For Eczema, Psoriasis + Other Skin Rashes?
195: Is There Hope For Thin Skin From Topical Steroid Cream Use? w/ Dr. Hadar Lev-Tov FULL TRANSCRIPT
Jennifer: Thank you so much for joining us back on the show, Dr. Lev-Tov. It's such an honor to have you here again.
Dr. Lev-Tov: It's my pleasure, Jennifer. And actually you should know that I recently saw a patient who said, I heard you on a podcast. And I said, Oh really? Yeah, I have a podcast. And they said, no, no, but you were a guest. I said, Oh, that podcast. That's awesome. So thank you. We did that one on hidradenitis suppurativa,
Jennifer: Yes.
Dr. Lev-Tov: Which I was very proud of to increase knowledge about this. And hopefully someone is listening and were able to learn something. So it's a great pleasure to be back. Thank you.
Jennifer: Well that is great to hear. I'm glad that we're… I love that this can be a vehicle to help support people find helpful partners on their journey. And that's so, so important. So today we're going to dive into a topic that I actually get a lot of questions on. And to be honest, I don't fully know what to tell people. So let's say you've used topical steroids for years, and especially, you've used it on your face where your thin… Your skin, excuse me, starts to get thin.
Dr. Lev-Tov: Right.
Jennifer: Okay. So let's first say, why does this happen? Why does the skin get thin with topical steroid cream use?
Dr. Lev-Tov: Yeah, so I would like to take a step back for a second.
Jennifer: Oh. Please.
Dr. Lev-Tov: And just highlight that the use of corticosteroids and topical corticosteroid specifically has been going on since the 50s. In fact, some famous dermatologist won… Not dermatologist, but doctors won Nobel prize for this. And it's been saving lives systemically and also topically really for the first time after a millennia, allowed dermatologist to treat really complex conditions. People with all kinds of types of eczema and psoriasis. And so more recently, there's a lot of fear of corticosteroids and even the topical one. And that fear, I think, got blown a little out of proportion. I mean, I think that there are certain risks, just like any medication that you use. And perhaps there's a lot of overuse of those because for some doctors it's kind of hard to make a clinical diagnosis, especially if you weren't trained, right.
Dr. Lev-Tov: If you're in primary care and your patient comes in, and they're very potent and effective. So they can take even a disease, that's not necessarily what we call steroid responsive and then make it look good. So you can treat an infection and mask it because it's such a potent immune suppressor. And so, I think it kind of got bad rep. And one of the side effects you're mentioning is the thinning of the skin. But in reality, if used appropriately, those side effects can be avoided. So I really instruct my patients… First of all, follow your doctor's instruction. But especially in eczema and psoriasis, which is one of the more common uses of topical steroids is, if you are going to use it, use it on the red, rough itchy skin. Use it on the disease skin. Try to avoid applying it to normal skin. And that's how you can avoid the side effects that we're talking about.
Dr. Lev-Tov: Also, you want to listen to your doctor if they say, use this kind of strength of topical steroids on that rash specifically. And it's going to work. Don't assume that now this will work on any other rash. And this is where problems start, right? So I'll give you an example. A patient has, let's say some psoriasis or eczematous dermatitis, and they will apply this cream on their leg. And voila, it works. Two weeks later they're like, Oh my God, this thing is gone. And I'm very happy. Now they start getting acne on their face just because people do. And they start using this topical steroids on their face, a big no-no. Okay. So now they start doing that. And all of a sudden their acne gets better because guess what? Very potent anti-inflammatory, right. And acne has a lot of inflammation.
Dr. Lev-Tov: But then after a while, it starts to cause the side effect. And this is where we're getting to your questions about thinning. So topical corticosteroids and systemic corticosteroids have an effect on the skin causing thinning of the top layer of the skin called the epidermis. And then also they have that same effect on the deeper layer of the skin. So by and large, they can lead to atrophy there. So the overall net effect is thinning of the skin. And that shows all of a sudden blood vessels, for example. And you can tell immediately when a patient with psoriasis, for example, comes to see me, and they've been treating with topical corticosteroids, I can kind of see that shiny skin on top that suggests that the epidermis is thin, that top layer. And I can tell already that have been applying it.
Dr. Lev-Tov: So if they do it as directed for a short period of time to the disease skin, they're okay. But when you start applying it to skin that's already thin to begin with, like on your face or on the genitalia, this is where very quickly you can get into trouble. Or let's say in the armpits, right? The skin there is thin. And then you apply it in sort of under occlusion, which makes it penetrate even more. So the other thing is that many topical corticosteroids can penetrate very effectively into the skin and that's why they're useful. But then they can go and affect the deeper layers. So they can lead the thinning. And in extreme cases, also with systemic corticosteroids, can lead to these stretch marks which all have to do with reduction of growth there on the skin layers.
Jennifer: So when this happens, say you're there, you're at that point where you're like, Oh my goodness, my skin is so thin. I don't know what to do. Is it possible to actually reverse that?
Dr. Lev-Tov: Very tough. I'm going to say,
Jennifer: Oh boy.
Dr. Lev-Tov: Straight up. Yeah, very tough. There's other side effects to topical corticosteroids, that are reversible. You can get acne from that or acne like rashes, rosacea type rashes. So your face is kind of red with bumps. So those kinds of conditions, if you withdraw the steroids slowly and replace it with other anti-inflammatory, then you're okay. But once you get those thinning of the skin and even stretch marks, it's incredibly hard to change. I can tell you, rarely I work… One of my areas of interest is wounds. And I have a few patients that have been for whatever reason, they needed to be on long-term systemic steroids. And they get really bad stretch marks so much so that they get wounds. The skin is so thin there.
Jennifer: Oh my goodness.
Dr. Lev-Tov: And it's a challenge, right? So, I got to say the best treatment is to avoid it. Now let's say, really you have this, there is some evidence that sometimes topical retinoids, people know these products, Tretinoin and others, they can help to sometimes induce some growth of collagen. Which is what we need for the deep layer of the skin. So they can induce some of that and that can work, but nothing is perfect. For stretch marks, there's some lasers that can maybe help, but again, the effect is minimal. So this is really where prevention is key. And that's why I started with understanding how to use these medications, following your doctor's instruction, but also having some common sense, understanding that they're very potent. And they need to be used just exactly where they are. It's like you can get a knife in your home, but you're not going to go do surgery on yourself just because you have a knife. Right. So by the same token, if you have a potent medication in your home, you're not just going to start using it, Willy nilly on stuff, because it worked for something else.
Jennifer: And with this situation, like say, you do have that thin skin. And we talked a lot in that previous episode, which I encourage everyone to listen to. Because it wasn't just about HS, we also talked a lot about wound care, which I think is really important. So you mentioned that thinning of the skin can result in wounds that can show up. Is that from… I think from itching could be one way. So if you have nails and you're itching your skin. Are there any steps people can take that could help protect the skin little bit more? Or if they do have wounds, is that the time to go back to someone like yourself? Who's a wound specialist, so to speak. To help make sure that it heals.
Dr. Lev-Tov: Yes. So, for sure. So like we've said, the topical steroids and systemic steroids, even more, they inhibit that collagen production. And that's a problem because you need that to heal a wound. And they also have an effect on the way that wounds heal from the top of the skin layer, the keratinocytes or the epithelium, kind of top closing of the wound. And so the first thing you have to do is stop it. And I got to say that a lot of times people come in, people who have let's say some connective tissue diseases like lupus or dermatomyositis, and it's a very effective treatment for them. And they may be on very low doses, but nonetheless, those doses make a difference for them.
Dr. Lev-Tov: And so you got to ask yourself, is there an alternative? That's the first step is to withdraw the offending agent. And the good news is that… And I want to highlight this. So when you go talk to your doctor, you should always ask about alternative. Because nowadays more and more, we have more alternatives. So we have topical calcineurin inhibitors like topical tacrolimus, for example, is one of them. And more recently we have something called crisaborole. The product name is known as EUCRISA. So those are new medications that are on the market that can potentially treat inflammatory conditions that are not topical corticosteroids. And then if you do get to… So the first thing is withdraw the offensive drug and try to switch it with something that will maintain your success with the steroid, but not cause the side effect.
Dr. Lev-Tov: And then you're down to good old fashioned wound care. And it really is going to depend on where the wound is and what needs to be done. But generally speaking, if you withdraw the offensive drug and you apply good wound care, slowly but surely these wounds heal. The challenge is with the recurrence, right? So the skin is so thin that every little trauma can hurt. So you got to be careful with that. You can use protective dressings as well for areas of high friction. You can use Silicon. There's some Silicon tapes that I like that are very good in protecting. You can use foams depending if the patient can't move and have these areas. But by and large, I would say that my approach with the use of topical corticosteroids and I think most rheumatologists would agree, is if you have to use in the beginning, some high potency topical steroids, very quickly reduce it, as the inflammation is reduced. Reduce it and then switch to a non-steroidal. And that's true both systemically and topically, right? So we have other alternative.
Jennifer: Wow, man, this is super interesting stuff. I mean, I know that for someone who's in this boat, they're like, I don't feel like this is interesting. I just want it to be fixed. But just listening to you talk about it clinically, at least for me as a little bit of a nerd, it is really interesting that we do have more options. But also looking at it from so many different perspectives. And I do appreciate too, you reminding people that we do have to be careful with what we're putting on different areas. Because higher potency steroids, like you said, that might work on your legs, might not be a good idea for your face and other areas.
Dr. Lev-Tov: Right.
Jennifer: And that's where you should defer to your physician to make sure that you're using them appropriately and as little as possible. So you're not just like, it's an everyday thing for years.
Dr. Lev-Tov: Yeah. And be a smart consumer. Right. So that's, I guess the key message is be a smart consumer. Don't be afraid of the product, just understand how you can use it. And always ask your doctor, okay, I'm going to use this, but what's my exit strategy, right? Because now there are agents that can serve as your parachute to get to get out of there. So, when the listeners out there are thinking about, they have rashes that are bad and they need the steroids to get good effect, you have to also remember what can I do after? So the first few weeks I'm going to use it. It's going to be good. What is my exit strategy? And challenge your physician. Ask them, what do I do after this? What do we do to maintain the success?
Dr. Lev-Tov: And we have good evidence in eczema for example, there's good evidence that, these kiddos, they get the rashes in the same areas all the time. So if you use a mid potency topical steroid, right, they'll get good in even about a week. Right. And there's good evidence that if after that, you just twice a week use an alternative, like a topical calcineurin inhibitor, sorry for the fancy name, but just a steroid at alternative.
Jennifer: Sure.
Dr. Lev-Tov: If you use it there twice a week, you can prevent those recurrences. And so not only are you avoiding the side effect of using a topical steroid on the skin that's already healed, you're not going to get to the problem. You're going to prevent it. So challenge your doctors. And board certified dermatologists know this. They are the good people to go for. And a lot of times there's a problem with access to specialty care. That's okay. Even if you get your one appointment there, your primary care doctor can take instructions later and help you. But be a wise consumer when you talk to your doctor.
Jennifer: Yeah. Well, I just want to thank you for… I know we had a short time to talk about this, but I really appreciate the time that you've made. And I hope that we can have you back sometime and dive deeper into some of your specialties because you definitely have such a great, unique perspective. And I deeply appreciate it.
Dr. Lev-Tov: Oh, thank you, Jennifer. It's my pleasure. Anytime.
