Multiple Cutaneous Infections Secondary to Inadvertent Use of Systemic Steroids

Introduction

Steroids are the mainstay of treatment for a lot of dermatological disorders.^[1] They are very effective in controlling inflammatory dermatosis because of their fast onset of action and low cost.^[2] Due to their over-the-counter availability, using old prescriptions for a new recurrent rash, sharing prescriptions among family and friends, availing these drugs from chemist shops without asking for a prescription, and store pharmacists sometimes dispensing these drugs making these drugs a double-edged sword.^[3] The use of steroids has a wide variety of side effects, which are both dose and time related such as immunosuppression, osteoporosis, myopathy, the elevation of blood glucose levels, hypothalamic–pituitary–adrenal axis suppression, growth impairment, and thinning of skin.^[4] Herein, we report a case of a 43-year-old male with multiple cutaneous infections and infestation owing to systemic steroid abuse.

Case Report

A 43-year-old male presented to the dermatology outpatient department with complaints of raised hyperpigmented lesions on his foreskin and his glans penis for about 2 months, itching on his glans penis for about 30 days, and itching on his whole body for about the past 20 days. On probing history, the patient was an old case of pemphigus vulgaris who was being treated with oral steroids but did not follow-up for subsequent check-ups. He was earlier prescribed prednisolone 40 mg tablet to be taken orally once per day by the treating physician during the active stage of his disease.

The patient continued the above-mentioned medication for about 9 months with partial relief from the symptoms of the disease it was originally prescribed for. The patient did not follow-up with his doctor during this period. The patient had a history of unprotected sexual contact with some known females multiple times while away from home for work.

On examination, the patient had multiple excoriated papules over his whole body and nodules on his scrotal and penile skin (black pointers) [Figures 1 and 2] with facial sparing, hyperpigmented verrucous lesions on his groin, foreskin, and glans penis with whitish deposits (on glans lesions) and induration of his foreskin (black pointers) [Figures 3 and 4], annular plaques on his lower back, both buttocks, and left thigh [Figure 5].

OPEN IN VIEWER Figure 1.

Verrucous lesions in the groin region and nodules on the scrotal and penile skin (black pointers)

OPEN IN VIEWER Figure 2.

Multiple papules with excoriations in axilla

OPEN IN VIEWER Figure 3.

Skin colored and hyperpigmented verrucous lesions on the foreskin and in the groin region (black pointers)

OPEN IN VIEWER Figure 4.

Verrucous lesions with whitish deposits on the inner surface of the foreskin and on glans penis (black pointers)

OPEN IN VIEWER Figure 5.

Hyperpigmented annular plaques on the lower back, both buttocks, and left thigh dorsal surface

Discussion

In India, corticosteroids are one of the most abused medications, and awareness of the harmful effects injudicious the use of steroids needs to be created.^[5] It is very important to stop the use of steroids for the incorrect indication. In contrast to hospital pharmacies, where a prescription is always required for dispensing more medication, pharmacies in the community do not always practice the same. Unsupervised use of this class of drug leads to a wide array of side effects that people are usually unaware of.^[6]

Side effects of oral steroids include immunosuppression, weight gain, sleep disorders, high blood pressure, elevated blood sugar levels, osteoporosis, skin atrophy, acne, risk of thrombosis, cataracts or glaucoma, psychiatric disturbances, stomach ulcers, etc.^[7] Owing to the immunosuppression caused by the oral steroids the patient was taking (tablet prednisone 40 mg in this case), the patient had contacted multiple, extensive cutaneous infections, which were diagnosed with tinea cruris et corporis, nodular scabies, genital warts, and candida balanoposthitis along with a few lesions of relapsed pemphigus vulgaris.

Conclusion

This case puts light on the often overlooked issue of injudicious use of corticosteroids, which, among many other drugs, is misused without addressing the risks involved. This class of drugs is available over-the-counter in India, adding to the potential abuse. Such cases highlight the need for vigilance and regulation for dispense of such medications without a prescription from a registered medical practitioner. The case in the discussion also highlights the need for regular follow-ups with their doctor and to avoid self-medication.