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Local effects are atrophy and striae due to reduced synthesis of collagen, telangiectasia, and purpura (Figure 8.3). The telangiectasia are due to dilatation of the capillary vessels. Some of the change may be reversible if the treatment responsible is stopped.

 A papular, erythematous eruption is sometimes seen on the thighs, buttocks, and inguinal folds. This has many features in common with peri‐oral dermatitis – a rosacea‐like condition seen on the peri‐oral skin of young females who have been applying topical steroids. The treatment is to withdraw the topical steroid slowly, and oral tetracyclines may be needed at the same time.

 If a fungal infection is mistaken for an eczematous process and a topical steroid applied, the scaling is lost and is replaced by papules and nodules without the usual features of tinea cruris. This picture is then termed tinea incognito (see Chapter 19) and may require systemic antifungals for treatment.

 Reactivation of viral infection such as human papillomavirus (HPV) and herpes simplex can occur. This can often respond to a reduction in potency of the steroid, and in the case of herpes simplex, a prophylactic dose of aciclovir (200–400 mg twice daily) can be given if intensive potent steroid treatment is needed as in the induction regimen for lichen sclerosus.Figure 8.3 Steroid telangiectasia and atrophy in a patient using excessive quantities of topical steroid.

 Contact allergy can occur to the steroid molecule itself. This is more common with the non‐fluorinated preparation [11].

 Prolonged use of a topical steroid with occlusive nappies has been implicated in infantile gluteal granuloma.