Corticosteroids creams or lotions are commonly prescribed to reduce inflammation that causes facial redness. They’re also the main ingredient in popular nasal sprays that aim to combat inflammatory responses that cause sinus issues. Now a recently published report in the journal Archives of Dermatological Research suggests that these widely prescribed medications may have a link with rosacea-like skin redness.
The authors, led by Erum Ilyas, MD, an academic chair and associate professor in Drexel University’s College of Medicine, note that the findings serve as an early signal that deserves further study, not proof that nasal steroid sprays cause rosacea. That said, the authors encourage patients to disclose with their doctor any over-the-counter nasal spray use when experiencing unexplained facial redness.
A total of 155 patients answered a 21-question survey about any rosacea-associated symptoms, such as facial redness, eyelid irritation and stinging/burning, among others, along with questions about frequency and duration of use of nasal sprays that contain the commonly used corticosteroid called fluticasone propionate.
The Drexel News Blog checked in with Ilyas, the senior author on the report, about what the team found and what it means for allergy patients experiencing facial redness.
Why did you decide to explore the potential relationship between corticosteroid-containing nasal sprays, particularly fluticasone propionate, and rosacea-like symptoms?
We know that corticosteroids applied directly to facial skin can sometimes trigger rosacea-like changes. Nasal steroid sprays such as fluticasone are widely used, including over the counter, but their relationship to facial symptoms has received much less study. In practice, I have noticed that many of my patients that have recurrent rosacea flares were also using these nasal sprays and most did not disclose it until asked. What is always tricky, clinically speaking, is that these flares will actually appear better while using the sprays. Steroid induced rosacea is a rebound flare effect after stopping use of steroids. In other words, the connection between using the spray and seeing the flare is not as obvious because it happens after you stop using them!
These sprays are over the counter so oftentimes these products are not given the same attention as a prescription product. We wanted to see whether people who use these sprays report more rosacea-like symptoms to confirm my clinical observation, and whether symptom patterns differ with how often or how long they use them. This was an exploratory study: it can identify an association, but it cannot show that the spray caused the symptoms.
What was the main finding from the study?
In our survey of 155 people, those who reported using fluticasone more frequently or for longer tended to report a greater number of rosacea-like symptoms. When we looked at each symptom separately, facial redness was the only one that differed significantly across use groups. The strongest pattern was among people who had used it for less than three months, though people reporting longer-term use also tended to report more symptoms.
We cannot give a reliable “out of 100 nasal steroid spray users” estimate from this study. It was a small, voluntary survey, not a study that followed a representative group of users over time, and it asked about self-reported symptoms rather than clinician-diagnosed rosacea. It also did not establish whether the symptoms began after starting the spray. So, the findings describe a pattern in our respondents, not the likelihood that an individual nasal steroid spray user will develop rosacea.
Interestingly, we also have another study we published in Pediatric Dermatology based on a large database called TrinetX. We examined health records for children using nasal or inhaled corticosteroids and looked at a different condition: newly documented perioral dermatitis, which is thought to be a variant of rosacea. Within a year, that diagnosis was recorded in about 6 out of every 10,000 children in the corticosteroid group, compared with about 3 out of every 10,000 matched children in the comparison group. That gives a sense of the small absolute difference observed in that study, but it should not be used as an estimate of rosacea risk for someone taking nasal steroid sprays since the study involved children, combined nasal and inhaled medications and assessed perioral dermatitis rather than rosacea.
How might pre-existing conditions have influenced the results?
Pre-existing conditions and other triggers for facial redness and rosacea-like symptoms could have influenced the results in several ways. People use these sprays because they have conditions such as allergic rhinitis or sinus problems, and those conditions may be linked with other health or skin factors that affect facial symptoms. People with more severe symptoms may also use the spray more often, creating a possible connection between use and symptoms even if the spray itself is not the cause. We could not independently assess the contribution of those underlying conditions or adjust for all relevant factors, such as other medications, skin treatments or lifestyle factors. That is one reason we interpret the findings cautiously.
Why is the possibility of reduced or inconsistent use causing rebound vascular reactivity important?
Corticosteroids applied to the facial skin topically have a well-documented risk of steroid- induced rosacea. Corticosteroids can reduce inflammation, which may temporarily make redness less noticeable. One proposed explanation is that when the medication’s effect wears off, especially with inconsistent use, blood vessels may become more reactive, and redness may return or appear worse. This is almost like a rebound effect. A person might then continue using the spray because it seems to help, even if symptoms fluctuate.
We did not track changes in use over time or measure blood-vessel changes, so this remains a hypothesis. It is a question we would like future research to examine, ideally by following people over time and recording how their use and symptoms change together.
Were you surprised that facial redness was the only symptom that differed significantly?
I was not surprised by facial redness as the only symptom that differed significantly at all for a simple practical reason. In my experience, those using steroid nasal sprays have times when they use them consistently and times of inconsistent use when nasal symptoms are not as severe. While in use, symptoms of rosacea will be suppressed so more significant flares will not be noticed. Participants who used nasal steroid sprays more often or for longer tended to report a higher overall number of symptoms, but facial redness was the only individual symptom that differed significantly across the use groups. With chronic use however it is possible for more of a baseline level of redness that persists and fluctuates at times but inconsistently because the intensity will reflect when the spray is in use.
Can the Rosascreen survey you used distinguish rosacea from other causes of redness?
Rosascreen is a screening questionnaire, not a diagnostic examination. It helps identify symptoms associated with rosacea, but it cannot determine whether redness is rosacea or something else. Redness can have many causes, so a clinician would need to consider the person’s history and examine their skin.
Should someone with rosacea-like symptoms talk with a dermatologist, allergist or both?
If someone has persistent or bothersome facial redness or other skin symptoms, it is reasonable to discuss them with a dermatologist. They should also disclose their history of allergies or nasal symptoms and about their spray use, including over-the-counter products and how often they use them.
People should not stop a treatment they rely on or change how they use it based on this survey alone. The next useful step is individualized care based on what your experience dictates. I have seen different scenarios play out. Some cannot stop using their products and will need better rosacea management to support their skin with an understanding that chronic management may be needed while others may be able to consider alternative nasal or congestion products based on the severity of those symptoms. This is why working with your doctor is so important as each case will require a personalized approach.
Reporters interested in talking with Ilyas should contact Greg Richter, assistant director, News & Media Relations, at gdr33@drexel.edu or 215.895.2614.
