Images in Dermatology
Topical corticosteroid induced ulcerated striae
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Verma, Bhushan Madke" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Shyam B." "apellidos" => "Verma" "email" => array:1 [ 0 => "skindiaverma@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Bhushan" "apellidos" => "Madke" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Nirvan Skin Clinic, Makarpura, Vadodara, India" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Datta Meghe Institute of Medical Sciences (Deemed University), Jawaharlal Nehru Medical College, Sawangi Meghe, Wardha, India" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 703 "Ancho" => 1305 "Tamanyo" => 171623 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A), Two superficial oval ulcers over striae in the inguinal region. (B), Beefy red oval ulcer over a wide atrophic stria with telangiectasia, extending from the anterior to the inferior aspect of breast. Active <span class="elsevierStyleItalic">tinea corporis</span> is observed.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">The authors report four cases of ulcerated striae following misuse of fixed-dose combinations (FDC) creams containing clobetasol propionate with antifungal and antibacterial agents. The present cases were overweight, between 27 − 40 years of age, and exhibited wide striae with secondary ulcerations. Three patients developed them after applying the implicated FDC creams for four months, five weeks, and five months, respectively (<a class="elsevierStyleCrossRef" href="#fig0005">Figs. 1</a> A−B, <a class="elsevierStyleCrossRef" href="#fig0010">2</a>A). The fourth patient (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B) had preexisting striae following two pregnancies, many of which increased in size and ulcerated during the period of FDC application. Most ulcers were oval, some showing overhanging borders, whereas large ulcers frequently adopted the pattern of striae (<a class="elsevierStyleCrossRef" href="#fig0010">Figs. 2</a> A−B). All ulcers were painful and were restricted to the striae. There was evidence of steroid-modified tinea corporis and history of erratic intake of oral antifungal drugs in all patients. Routine investigations were normal, including morning and evening serum cortisol levels. No biopsies were performed in view of the obvious clinical diagnosis and the possibility of delayed healing of TCS treated striae.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0010" class="elsevierStylePara elsevierViewall">The literature on ulcerated striae (US) is scarce, and the majority of case reports implicate bevacuzimab, an anti-VEGF drug, used with high dose systemic corticosteroids, in the treatment of invasive brain tumors such glioblastomas.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Use of potent systemic or topical corticosteroids alone have also been implicated occasionally.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Though not very common, the authors believe that the onset of US as a side effect of potent and super-potent topical steroids is underreported.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Such creams are most frequently available as FDC, even over the counter, and are extensively misused in the treatment of superficial fungal infections in South Asia, Africa, and in many developing countries.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The authors cite some old reports for their specific clinical relevance in the presents cases.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5,6</span></a> Association of striae with steroid containing FDCs (triamcinolone, neomycin, gramicidin, or nystatin) dates back to 1963.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Their predilection for warm, moist places prone to friction is known.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5,6</span></a> They have been observed to occur as early as three weeks of application of TCS.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a> Steroid-induced striae are wider than common SD. Some preexistent striae are known to enlarge upon application of TCS and new striae are observed to appear even after discontinuation of the cream.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Histopathological changes in striae include epidermal atrophy, loss of rete ridges, increased vascularity in striae rubra, less vascularity in striae alba, and dermal changes in extracellular matrix and fibrillary component of collagen and elastin.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> However, the pathologic steps underlying ulceration in striae have not been elucidated. Interestingly, steroids are known to have anti-VEGF properties, similarly to bevacizumab.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> While twelve cases of bevacizumab in combination with systemic steroids are reported in the English literature, both drugs individually can cause ulceration.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,9,10</span></a> The authors hypothesize that long-term application of a potent topical steroid such as clobetasol may lead to slow ischemia, on account of its vasoconstrictive and anti-VEGF properties, leading to ulceration.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> The well-documented features of profound epidermal atrophy, high degree of vascularity, limited elasticity, and reduced tensile strength of steroid induced striae reinforce this hypothesis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion, the authors presented four cases of patients with <span class="elsevierStyleItalic">tinea corporis</span> and US induced by FDCs containing clobetasol propionate, which are widely misused in India. The authors believe this is an underreported side effect of the FDCs that are fueling the epidemic-like situation of tinea corporis in India. Drug policy makers need to regulate permissions to manufacture and sell such hazardous and often irrational creams. It is also time for agencies such as the World Health Organization to look into this menace. Finally, the mechanism of ulceration of steroid induced striae needs to be further studied and elucidated.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Financial support</span><p id="par0030" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Authors’ contributions</span><p id="par0035" class="elsevierStylePara elsevierViewall">Shyam B. Verma: Approval of the final version of the manuscript; preparation and writing of the manuscript; manuscript critical review.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Bhushan Madke: Preparation and writing of the manuscript; critical literature review; manuscript critical review.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres1461421" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1331605" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Financial support" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Authors’ contributions" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-06-15" "fechaAceptado" => "2020-07-28" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1331605" "palabras" => array:4 [ 0 => "Adverse effects" 1 => "Striae distensae" 2 => "Topical steroid" 3 => "Ulceration" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We report four cases of ulcerated striae following misuse of fixed dose combinations creams containing clobetasol propionate with antifungal and antibacterial agents.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Verma SB, Madke B. Topical corticosteroid induced ulcerated striae. An Bras Dermatol. 2021;96:94–96.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Nirvan Skin Clinic, Makarpura, Vadodara and Datta Meghe Institute of Medical Sciences (Deemed University), Jawaharlal Nehru Medical College, SawangiMeghe, Wardha, India.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 703 "Ancho" => 1305 "Tamanyo" => 171623 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A), Two superficial oval ulcers over striae in the inguinal region. (B), Beefy red oval ulcer over a wide atrophic stria with telangiectasia, extending from the anterior to the inferior aspect of breast. Active <span class="elsevierStyleItalic">tinea corporis</span> is observed.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 701 "Ancho" => 1305 "Tamanyo" => 182787 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A), Multiple, wide, beefy red, ulcerated striae over abdomen. Similar appearance, as well as linearly oriented oval ulcers in inguinal region. Widespread steroid-modified <span class="elsevierStyleItalic">tinea corporis</span> is observed. (B), Beefy red linear ulcers with hyperpigmented overhanging borders limited to the striae. Two superficial ulcerations on adjacent striae. <span class="elsevierStyleItalic">Tinea corporis</span> is observedin the background.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ulceration of steroid-induced striae distensae in a patient with a rare brain tumor on bevacizumab" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E. Pilitsi" 1 => "S. Wang" 2 => "M. Braniecki" 3 => "M.M. Tsoukas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Clin Oncol." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 20 | 10 | 30 |
| 2024 October | 112 | 67 | 179 |
| 2024 September | 134 | 78 | 212 |
| 2024 August | 153 | 105 | 258 |
| 2024 July | 121 | 121 | 242 |
| 2024 June | 104 | 87 | 191 |
| 2024 May | 84 | 70 | 154 |
| 2024 April | 92 | 80 | 172 |
| 2024 March | 76 | 87 | 163 |
| 2024 February | 110 | 84 | 194 |
| 2024 January | 67 | 44 | 111 |
| 2023 December | 59 | 67 | 126 |
| 2023 November | 81 | 76 | 157 |
| 2023 October | 63 | 79 | 142 |
| 2023 September | 118 | 81 | 199 |
| 2023 August | 65 | 41 | 106 |
| 2023 July | 62 | 49 | 111 |
| 2023 June | 50 | 47 | 97 |
| 2023 May | 57 | 25 | 82 |
| 2023 April | 37 | 16 | 53 |
| 2023 March | 67 | 41 | 108 |
| 2023 February | 56 | 35 | 91 |
| 2023 January | 43 | 38 | 81 |
| 2022 December | 49 | 36 | 85 |
| 2022 November | 52 | 47 | 99 |
| 2022 October | 122 | 53 | 175 |
| 2022 September | 72 | 69 | 141 |
| 2022 August | 41 | 29 | 70 |
| 2022 July | 41 | 58 | 99 |
| 2022 June | 43 | 54 | 97 |
| 2022 May | 42 | 52 | 94 |
| 2022 April | 60 | 54 | 114 |
| 2022 March | 48 | 67 | 115 |
| 2022 February | 48 | 40 | 88 |
| 2022 January | 98 | 77 | 175 |
| 2021 December | 68 | 52 | 120 |
| 2021 November | 57 | 69 | 126 |
| 2021 October | 62 | 87 | 149 |
| 2021 September | 51 | 61 | 112 |
| 2021 August | 57 | 62 | 119 |
| 2021 July | 46 | 61 | 107 |
| 2021 June | 63 | 68 | 131 |
| 2021 May | 114 | 110 | 224 |
| 2021 April | 204 | 394 | 598 |
| 2021 March | 164 | 96 | 260 |
| 2021 February | 61 | 39 | 100 |
| 2021 January | 29 | 15 | 44 |
| 2020 December | 5 | 7 | 12 |
| 2020 November | 1 | 2 | 3 |
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