INTRODUCTION
Steroid-induced rosacea (SIR), also known as perioral dermatitis, is a withdrawal phenomenon that can occur following prolonged use of topical steroids on the face, especially with higher potency corticosteroids. This condition presents with symptoms similar to those of rosacea, which is characterized by the appearance of erythema, telangiectasia, and pustules. This is thought to be due to the steroid induced epidermal atrophy, rebound inflammation, vasodilation, and proinflammatory cytokine release, resulting in steroid rosacea. Although conventional treatments, such as topical antibiotics, second generation tetracycline antibiotics (eg, doxycycline), and antihistamines, are commonly used, SIR can still be challenging to manage.1 Novel therapeutic approaches are needed to address this condition. We report a case of a patient with reactive steroid rosacea who experienced significant improvement with the third-generation tetracycline, sarecycline.
CASE REPORT
Our patient, a 54-year-old woman, was taking clobetasol steroids periodically for 15 years due to itchy dry patches on her scalp. On examination, the patient exhibited red papules and pimples with scales on her face that were accompanied by scaling, peeling, and a waxy texture (Figure 1). The patient was not currently on medications but had previously used tacrolimus, ketoconazole, and clobetasol. After her diagnosis of steroid rosacea, she was recommended to stop all steroids, start ruxolitinib cream twice
daily, and if improvement, start laser therapy for erythema. After almost one month of no improvement, sarecycline was added to the current regimen. One month later the patient showed significant improvement with less inflammation, however, the skin was still spotty and not smooth (Figure 2). Upon continuing sarecycline for one more month the patient's face was clear of perioral dermatitis.
daily, and if improvement, start laser therapy for erythema. After almost one month of no improvement, sarecycline was added to the current regimen. One month later the patient showed significant improvement with less inflammation, however, the skin was still spotty and not smooth (Figure 2). Upon continuing sarecycline for one more month the patient's face was clear of perioral dermatitis.
DISCUSSION
Steroid-induced rosacea is a well-recognized adverse effect of long-term topical or systemic steroid use, which paradoxically induces proinflammatory gene expression, leading to rebound inflammation upon discontinuation. Furthermore, steroid rosacea has been associated with a dysregulated skin microbiome enriched with Propionibacterium acnes (P. acnes).2 In the present case report, we describe a patient with treatment-refractory SIR who achieved significant improvement with sarecycline, a novel third-generation tetracycline-class antibiotic. Sarecycline's potent activity against P. acnes likely contributed to the suppression of the dysbiotic microbiome, whereas its anti-inflammatory properties may have mitigated the rebound inflammation by modulating the upregulated immune response.3 Additionally, sarecycline's narrow spectrum of antibacterial activity yields a lower side effect profile than standard protocol broad-spectrum antibiotics as it leaves most of the beneficial bacteria unaffected.4 These findings suggest that sarecycline may represent a promising therapeutic option
