INTRODUCTION
Acne vulgaris, a chronic inflammatory skin condition characterized by papules, pustules, comedones, and nodules, imposes significant physical, psychological, and economic burdens.1 Acne affects 85% of adolescents but can continue to trouble adults1; it may also newly develop in adulthood or reappear after resolving.2
The 4 primary factors driving acne pathogenesis are inflammation, increased sebum production, epithelial hyperkeratinization, and overgrowth of Cutibacterium acnes.1 Androgens are the leading group of hormones involved in acne development, and testosterone, androstenedione, and cortisol levels correlate with disease severity.3 Recommended first-line treatment for acne vulgaris includes topical or systemic retinoids, topical or oral antimicrobials, and/or topical benzoyl peroxide (BPO), but alternative treatment options include steroids and steroidal molecules such as corticosteroids, combined oral contraceptives (COCs), and spironolactone.1 Steroids and related molecules are a valuable therapeutic class for acne because they address the hormonal aspects of acne pathogenesis while providing alternative treatment options for patients with acne refractory to antibiotics and other conventional treatments.1,4
Oral corticosteroids act as potent anti-inflammatory agents (Figure 1).7 By inhibiting pituitary adrenocorticotropic hormone (ACTH) production, oral corticosteroids also lower androgen
The 4 primary factors driving acne pathogenesis are inflammation, increased sebum production, epithelial hyperkeratinization, and overgrowth of Cutibacterium acnes.1 Androgens are the leading group of hormones involved in acne development, and testosterone, androstenedione, and cortisol levels correlate with disease severity.3 Recommended first-line treatment for acne vulgaris includes topical or systemic retinoids, topical or oral antimicrobials, and/or topical benzoyl peroxide (BPO), but alternative treatment options include steroids and steroidal molecules such as corticosteroids, combined oral contraceptives (COCs), and spironolactone.1 Steroids and related molecules are a valuable therapeutic class for acne because they address the hormonal aspects of acne pathogenesis while providing alternative treatment options for patients with acne refractory to antibiotics and other conventional treatments.1,4
This review provides an overview of the recommended use, mechanisms of action, and clinical evidence for steroids and steroidal molecules used for the treatment of acne. Key clinical considerations for the appropriate use of these treatments in patients with acne are also summarized.
Corticosteroids
Corticosteroids used for acne treatment comprise oral corticosteroids and intralesional corticosteroid injections (Table 1).1 Oral corticosteroids, mainly prednisone, are recommended upon initiation of standard treatment for patients with severe inflammatory acne,1 but their long-term adverse event (AE) profile precludes their use as primary acne therapies.1,5 Low-dose oral corticosteroids are recommended alone or in combination with COCs for patients with hyperandrogenism.1 Intralesional corticosteroid injections (triamcinolone acetonide 3.3-10 mg/mL) are recommended for the occasional treatment of individual acne nodules, lesions refractory to other treatments, and acne sequelae.1,6
Oral corticosteroids act as potent anti-inflammatory agents (Figure 1).7 By inhibiting pituitary adrenocorticotropic hormone (ACTH) production, oral corticosteroids also lower androgen
