The widespread misuse of skin creams and lotions that contain steroids in India is harmful and out of control, argues an expert in The BMJ this week.
Corticosteroids, also known as steroids, are anti-inflammatory medicines used for a range of conditions. However, these can lead to substantial and permanent damage, especially on thin skin, such as on the face and groin.
Side effects include pigmentation and breakdown of the skin, small and widened blood vessels on the skin, as well as bacterial and fungal infections. Misuse can lead to resistance of infections that can make these difficult to diagnose and treat.
Shyam B Verma, a consultant dermatologist based in Gujuarat, says that "Indian doctors are witnessing a pandemic of adverse effects induced by topical corticosteroids".
A study of 2,926 dermatology patients in 2013 showed that 433 (14.8%) were using topical steroids and 392 (90.5%) had harmful effects.
As required by law in India, strong steroids can be sold only with a registered medical practitioner's prescription. However, topical steroids are exempt and can be purchased over the counter. "This needs urgent revision," he says.
Another problem that leads to the inappropriate use of topical steroids is that too few specialist dermatologists are available. The majority of India's some 8,500 dermatologists are based in cities, while most of India's population are dispersed in villages.
"So many patients seek treatment for skin disease from primary care providers, including thousands of ayurvedic and homeopathic practitioners and unqualified charlatans," he explains.
"Although it is illegal, they may prescribe topical corticosteroids with little or no knowledge of dermatology," and many pharmacists "sell steroid creams without a prescription, ignoring the box warnings."
Due to costs and the inconvenience of specialist dermatological consultations, patients with prescriptions often re-purchase and share drugs with friends and relatives with similar symptoms.
In 2014-15, the market was worth Rs15.55bn, 11% higher than the previous year. Around 85% of the market comprises "steroid cocktails"--these are topical steroids that contain one or two antibiotics and antifungals.
"Sales of such products would be unthinkable in developed nations but even qualified medical practitioners in India are ignorant about rational prescribing," he explains, and calls for these "irrational combinations" to be banned.
"Most developed countries restrict sales of topical corticosteroids strictly by prescription, because they should be used judiciously, for appropriate indications and duration."
And the government of India should also ensure that topical steroids, except for those with low potency, are regulated appropriately in terms of production and sales, he argues.
"This problem highlights the low priority that dermatology receives in India," he argues, and calls for the "health ministry's drug technical advisory boards [to] include more dermatologists to advise the drug controller's office and state representatives."
In addition, he says "the public, as well as doctors of all specialties, need to be informed and educated about safe use of topical corticosteroids."