Drugs that change appearance—and other adverse effects

By Naveed Saleh, MD, MS
Published December 21, 2021

Key Takeaways

Although body-image concerns don’t represent mental illness on their own, they do influence mental health, exacerbating psychological distress, eating disorders, and decreased quality of life.

Unfortunately, mass media and social networks further contribute to body-image concerns. These images and ideas promote thinness, youthfulness, and flawlessness.

Drugs—both illicit and those prescribed by doctors—can alter appearance for the worse. These appearance changes should be noted by physicians and managed accordingly. For patients, disturbing changes in appearance due to drugs can motivate behavior change.

Here’s a closer look at four drugs that change appearance. 


There is no denying that glucocorticoids have benefits. They harbor, for instance, anti-inflammatory, vasoconstrictive, and immune suppressive properties that make them helpful for inflammatory skin diseases such as eczema. Negative side effects, however, can usurp these benefits and include muscle/skin atrophy, striae distensae, and acne.

Skin atrophy is one of the biggest concerns and affects all skin compartments including the stratum corneum, where it compromises barrier, and the dermis, where it stymies fibroblast and mast cell proliferation, as well as loss of support elements including elastin and collagen. Overall, steroids can lead to skin fragility, severe hypoplasia, tearing, and transparency.

Glucocorticoids catabolize skin and degrade proteins, break down fats, boost apoptosis, and more. The negative side effects of steroids occur first in the epidermis and then the dermis.

According to the authors of a review article published in Clinical, Cosmetic and Investigational Dermatology, physicians should be on the lookout for the negative effects of steroids. “It is of the utmost importance to limit as much as possible the use of GC, and when that is not possible, to try and administer the lowest dosage with the highest benefit to adverse effects ratio and with the shortest duration.”


One sign of drug misuse in patients is “meth mouth.” People dependent on methamphetamines have blackened, stained, and crumbling teeth, which cannot be saved and must be extracted. The mechanism underlying meth mouth is multifactorial and includes dry mouth, poor oral hygiene, cravings for sugar-sweetened beverages, and the acidic nature of meth.

In a study cited by the American Dental Association, 571 methamphetamine users were assessed. The investigators found that the users exhibited severe dental and periodontal disease, with older age and moderate/heavy use especially damaging. Women had increased rates of tooth loss and cavities, including those of the anterior mouth. Cigarette smoking was also associated with more severe caries. About 3% of users lacked teeth altogether, and 40% were embarrassed with their associated appearance.

According to the authors, the impact of meth use on the teeth is distinctive and alerts to undisclosed meth use. These signs can be used as a springboard to intervention, with dental appearance serving as a motivation for behavioral change.


The appearance of skin changes in those who inject heroin can be complex, thus the Center for Substance Abuse Treatment proposed a six-level photo classification system.

  1. Recent/old. Newer lesions such as inflammation or non-healed wounds are paired with older lesions such as scars or granulomas.

  2. Recent only. Examples include scabs, abscesses, and puncture wounds.

  3. Old only. Examples include hypo- and hyperpigmented granulomas, scars, and noninflamed thromboses.

  4. Conflictive. Lesion characteristics are indiscernible. 

  5. Unsure. Difficult to determine where the lesion derived.

  6. Inconsistent. Lesion probably doesn’t represent an injection site.

The authors stressed the clinical importance of categorizing lesions. “For those working in the health care and substance abuse fields, having the ability to distinguish drug injection lesions (ie, needle track marks) from lesions attributable to other factors may help facilitate accurate diagnoses and promote the delivery of effective treatments and interventions to reduce patient risk.”

NSAIDs and more

Hyperpigmentation of the skin can lead to psychological distress and is a common dermatologic issue. Drug-induced hyperpigmentation accounts for between 10% and 20% of acquired cases. Hyperpigmentation is due to an increase in melanocytes at the basal or suprabasal levels of the skin or the deposition of exogenous pigments such as iron or heavy metals.

In a small study published in the Journal of the American Board of Family Medicine, investigators assessed the most frequent agents involved in medication-induced skin hyperpigmentation and identified the following etiologies in decreasing order: nonsteroidal anti-inflammatory agents (NSAIDs), antihypertensive agents, antimalarials, antibiotics, antineoplastic agents, psychoactive agents, simvastatin, allopurinol, amiodarone and mucolytic. They noted hyperpigmentation of the mucosa in 25% of patients, with photograph-exposed areas accounting for 37.5% of cases. 

The diagnosis of drug-induced hyperpigmentation is difficult, with differential diagnoses including endocrine, metabolic, or idiopathic causes. Esthetic concerns are often voiced by the patients.

In the case of NSAIDs, these drugs may lead to hyperpigmentation by functioning as a hapten and binding to melanocytes, thus leading to cytotoxicity. This cytotoxicity usually results in a static, hyperpigmented skin rash. Common NSAIDs that cause hyperpigmentation include paracetamol, salicylates, and ibuprofen. 

 “Drug-induced hyperpigmentation is a relatively frequent reason for consultation, especially in polypharmacy patients,” stated the authors. “Family physicians and specialists should consider drugs as a cause of hyperpigmentation to facilitate the correct diagnosis and treatment.”

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