No Moisture Treatment for Topical Steroid Withdrawal

June 30, 2024

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If you’re struggling with the painful, debilitating symptoms of topical steroid withdrawal (TSW), also known as Red Skin Syndrome, you may be searching for treatments to help manage your condition and promote healing. One controversial approach that has gained attention in the TSW community is no moisture treatment (NMT).

In this comprehensive guide, we’ll take an in-depth look at what NMT involves, the potential risks and benefits, and what the scientific evidence says about its effectiveness for treating TSW. We’ll also explore other treatment options and support strategies to help you navigate your TSW journey with confidence and resilience.

Whether you’re considering trying NMT or simply want to learn more about this approach, I hope this article provides the information and insights you need to make informed decisions about your care. Let’s dive in!

What is No Moisture Treatment?

No moisture treatment, or NMT, is a protocol developed by Dr. Kenji Sato, a dermatologist in Japan who has been treating patients with TSW since 1994[4]. The goal of NMT is to allow the skin to dry out and heal as quickly as possible by avoiding all sources of moisture, both internal and external.

The key principles of NMT include[1][4]:

  • Completely stopping the use of all topical steroids and other topical medications
  • Limiting showers or baths to once or twice per week, for 1-2 minutes maximum
  • Avoiding the use of any moisturizers, oils, or emollients on the skin
  • Reducing fluid intake to around 1 liter per day, depending on body weight
  • Eating a diet adequate in protein to support skin healing
  • Exercising daily to promote circulation and skin regeneration
  • Going to bed early to maximize the skin’s healing processes during sleep
  • Allowing the skin to naturally shed and flake without manual exfoliation

Proponents of NMT argue that by depriving the skin of moisture, it is forced to quickly move through the stages of inflammation, oozing, and flaking that characterize TSW. This is thought to accelerate the healing process and allow healthy, steroid-free skin to emerge more rapidly than with other approaches.

However, NMT is highly controversial and not without risks. Critics argue that the severe drying and stress caused by NMT may actually prolong or worsen TSW symptoms, increase the risk of complications like infections, and be too difficult for many people to sustain[1].

It’s important to note that Dr. Sato’s published studies on NMT have been small and uncontrolled, and there is currently no strong scientific evidence proving that NMT is more effective than other treatments for TSW[1]. More research is needed to fully understand the risks and benefits of this approach.

If you’re considering trying NMT, it’s crucial to discuss it with a dermatologist or other healthcare provider experienced in treating TSW first. NMT should only be attempted under close medical supervision, as it can be very challenging and may not be appropriate for everyone.

Other Treatment Options for TSW

While there is no cure for TSW, there are several other treatment approaches that may help manage symptoms and support skin healing. The most appropriate treatment plan will depend on your individual symptoms, health history, and personal preferences.

It’s important to work closely with a dermatologist who understands TSW to develop a personalized treatment plan and adjust it as needed over time. Some common treatment options include:

Topical Steroid Tapering

The mainstay of TSW treatment is discontinuing the use of topical steroids, but this must be done carefully to minimize the risk of severe rebound symptoms[2]. Your doctor may recommend a gradual tapering schedule to slowly wean your skin off steroids over a period of weeks or months.

Tapering may involve using lower potency steroids, applying them less frequently, or diluting them with a moisturizer before eventually stopping altogether. Some doctors may prescribe a short course of oral steroids to help control inflammation during the tapering process[2].

It’s important to follow your doctor’s instructions carefully and not attempt to taper off steroids on your own, as this can lead to severe TSW flares.

Moisturization and Skin Care

Gentle, strategic moisturization is considered a cornerstone of TSW management by many dermatologists[2]. While NMT advocates avoiding all moisturizers, others argue that keeping the skin hydrated is crucial for maintaining the skin barrier, reducing inflammation, and preventing complications like infections.

The key is to use moisturizers that are free of common irritants, fragrances, and preservatives. Look for products with skin-identical ingredients like ceramides and natural oils to replenish moisture without clogging pores. Applying moisturizer to damp skin after bathing and using humidifiers to add moisture to the air can also be helpful[2].

Other gentle skin care practices that may provide relief include:

  • Using lukewarm water and mild, fragrance-free cleansers
  • Patting skin dry instead of rubbing
  • Applying cool compresses to inflamed areas
  • Wearing loose, breathable clothing made of natural fibers
  • Protecting skin from extreme temperatures and direct sunlight

Always introduce new products slowly and perform a patch test first to ensure your skin can tolerate them. Your dermatologist can provide personalized recommendations based on your skin type and symptoms.

Wet Wrap Therapy

For severe TSW flares with intense itch and inflammation, wet wrap therapy may provide short-term relief and promote skin healing. This involves applying topical medications or moisturizers to the skin, then covering the area with a layer of damp gauze or clothing followed by a layer of dry clothing[2].

Wet wraps are usually left on for several hours or overnight to deeply hydrate the skin and enhance the absorption of topical treatments. They can be especially helpful for treating hard-to-reach areas like the scalp, hands, and feet.

However, wet wraps can also increase the risk of skin infections, so they should only be used under the guidance of a dermatologist. Overuse of wet wraps can also lead to further skin thinning and dependence on moisture, so they’re typically reserved for short-term use during acute flares.

Medications

In addition to topical treatments, your doctor may prescribe oral medications to help control TSW symptoms and reduce inflammation. These may include:

  • Oral steroids: A short course of prednisone or another oral steroid may be used to quickly reduce severe inflammation and itch during the acute phase of TSW. Long-term use is avoided due to the risk of systemic side effects[2].
  • Antihistamines: Over-the-counter or prescription antihistamines can help relieve itching and improve sleep during TSW. Non-sedating antihistamines like cetirizine or loratadine are often used during the day, while sedating antihistamines like diphenhydramine may be helpful at night[2].
  • Immunosuppressants: In severe cases of TSW that don’t respond to other treatments, immunosuppressant drugs like cyclosporine, methotrexate, or mycophenolate mofetil may be prescribed to calm the overactive immune response. These medications can have serious side effects and require close monitoring by a doctor[2].
  • Antibiotics: If secondary skin infections develop, oral or topical antibiotics may be needed to prevent the infection from worsening or spreading. Symptoms of infection include increased redness, swelling, pain, warmth, or oozing of pus[2].
  • Dupilumab: A newer biologic medication called dupilumab has shown promise in reducing TSW symptoms in some people with a history of atopic dermatitis. However, more research is needed to confirm its safety and effectiveness for this specific use[3].

As with any medication, it’s important to discuss the potential risks and benefits with your doctor and follow their instructions for use carefully. Never stop taking a prescribed medication without first consulting your doctor.

Phototherapy

Phototherapy, also known as light therapy, involves exposing the skin to controlled amounts of natural or artificial light to reduce inflammation and promote healing. Several types of phototherapy have been used to treat TSW, including[2]:

  • Narrowband UVB: This type of phototherapy uses a specific wavelength of ultraviolet B (UVB) light to penetrate the skin and reduce inflammation. Treatments are typically done 2-3 times per week in a dermatologist’s office or with a home phototherapy unit.
  • PUVA: Psoralen plus UVA involves taking a medication called psoralen before exposing the skin to UVA light. This can help reduce inflammation and slow down skin cell growth. PUVA is usually reserved for more severe cases of TSW that haven’t responded to other treatments.
  • Natural sunlight: Cautious exposure to natural sunlight, starting with just a few minutes a day and gradually increasing as tolerated, may help improve TSW symptoms for some people. However, it’s important to avoid sunburn and protect the face and other sensitive areas with clothing or a broad-spectrum sunscreen.

Phototherapy can be an effective adjunctive treatment for TSW, but it may not be appropriate for everyone. It can cause side effects like skin dryness, itching, and increased skin aging over time. It may also not be covered by insurance in some cases.

Your dermatologist can help determine if phototherapy is right for you based on your individual symptoms and health history. They can also provide guidance on the appropriate dose and frequency of treatments to minimize risks.

Managing TSW Symptoms and Flares

In addition to medical treatments, there are several lifestyle and self-care strategies that can help you manage TSW symptoms and cope with flares. Here are some tips to consider:

Stress Reduction

Stress is a major trigger for TSW flares and can significantly impact your overall health and well-being. Developing a daily stress management routine can help calm your nervous system, reduce inflammation, and promote healing.

Some effective stress-reducing techniques include[5]:

  • Deep breathing exercises
  • Meditation or mindfulness practices
  • Gentle yoga or stretching
  • Spending time in nature
  • Engaging in hobbies or creative activities
  • Connecting with loved ones and support networks

It’s also important to prioritize self-care activities that nourish your mind and body, such as getting enough sleep, eating a balanced diet, and staying hydrated. Taking breaks from social media or other triggering environments can also be helpful.

If stress feels overwhelming or unmanageable, don’t hesitate to reach out to a mental health professional for additional support. Many people with TSW benefit from therapy, counseling, or support groups to help cope with the emotional impact of the condition.

Itch Management

Intense itching, also known as pruritus, is one of the most distressing symptoms of TSW. While it can be difficult to resist the urge to scratch, doing so can further damage the skin and lead to infections.

Some strategies for managing TSW-related itch include[5]:

  • Applying cool compresses or taking lukewarm baths
  • Using gentle, fragrance-free moisturizers to soothe the skin
  • Wearing loose, breathable clothing made of natural fibers
  • Keeping fingernails short and smooth to prevent skin damage
  • Distracting yourself with activities like reading, listening to music, or calling a friend
  • Using over-the-counter or prescription antihistamines as directed by your doctor
  • Trying relaxation techniques like deep breathing or visualization

If itch is severe or persistent, your doctor may prescribe stronger medications like gabapentin or oral corticosteroids to provide relief. Topical medications like calcineurin inhibitors or menthol-containing products may also be helpful for some people.

Skin Infection Prevention

One of the most serious potential complications of TSW is secondary skin infections, which can occur when bacteria or other microbes enter the skin through open wounds or cracks. Symptoms of infection may include increased redness, swelling, warmth, pain, or oozing of pus.

To reduce your risk of skin infections during TSW:

  • Keep skin clean and dry, using gentle cleansers and patting skin dry instead of rubbing
  • Apply moisturizers or prescription ointments as directed to prevent skin cracking and maintain barrier function
  • Cover open wounds with sterile bandages or dressings
  • Avoid scratching or picking at the skin, which can introduce bacteria
  • Wash hands frequently, especially before touching your face or skin
  • Avoid sharing personal items like towels, razors, or makeup brushes
  • Disinfect household surfaces and wash bedding regularly in hot water

If you suspect you may have a skin infection, contact your dermatologist right away for evaluation and treatment. Prompt treatment with antibiotics can help prevent the infection from worsening or spreading to other parts of the body.

Nutritional Support

What you eat can play a significant role in your skin health and overall well-being during TSW. While there is no one-size-fits-all diet for TSW, focusing on nutrient-dense whole foods and staying well-hydrated can support your body’s natural healing processes.

Some general dietary tips for TSW include[2]:

  • Eating a variety of colorful fruits and vegetables to get a range of vitamins, minerals, and antioxidants
  • Choosing lean proteins like chicken, fish, legumes, and eggs to support skin repair and immune function
  • Incorporating healthy fats from sources like avocados, nuts, seeds, and olive oil to reduce inflammation
  • Limiting processed foods, refined sugars, and artificial additives that can trigger inflammation
  • Staying hydrated with water, herbal tea, and other non-caffeinated beverages

Some people with TSW also find that eliminating certain foods or following specific diets like an elimination diet or low-histamine diet helps reduce their symptoms. However, it’s important to work with a registered dietitian or nutritionist before making significant changes to your diet to ensure you’re still meeting your nutritional needs.

Your dermatologist or primary care provider may also recommend certain supplements like omega-3 fatty acids, vitamin D, or probiotics to support skin health and immune function during TSW. However, always check with your doctor before starting any new supplement regimen.

Finding Support and Community

Coping with TSW can be an isolating and emotionally challenging experience, but you don’t have to go through it alone. Connecting with others who understand what you’re going through can provide valuable support, encouragement, and practical advice.

Some resources for finding TSW support and community include:

  • Online support groups: Social media platforms like Facebook and Instagram have many active TSW support groups where you can connect with others, share experiences, and get tips and encouragement. Some popular groups include the ITSAN TSW Support Group and the TSW Red Skin Syndrome Support Group[5].
  • In-person support groups: Some hospitals, dermatology clinics, or community organizations may offer in-person support groups for people with TSW or other skin conditions. Check with your local healthcare providers or search online for groups in your area.
  • TSW blogs and podcasts: Many people with TSW share their stories and experiences through personal blogs, vlogs, or podcasts. Reading or listening to these can help you feel less alone and provide inspiration and hope for healing. Some popular TSW bloggers include The Red Skin Diaries, TSW Healing, and Preventable: Protecting Our Largest Organ.
  • Counseling or therapy: If you’re struggling with the emotional impact of TSW, consider seeking professional counseling or therapy. A mental health provider who understands chronic skin conditions can help you develop coping strategies, manage stress and anxiety, and improve your overall quality of life.

Remember that everyone’s TSW journey is unique, and what works for one person may not work for another. Don’t compare your progress or timeline to others, and be gentle with yourself as you navigate the ups and downs of healing.

It can also be helpful to educate your loved ones, friends, and colleagues about TSW so they can better understand what you’re going through and how to support you. Sharing articles, videos, or personal stories can help raise awareness and reduce stigma around this often misunderstood condition.

The Bottom Line

Treating topical steroid withdrawal can be a complex and challenging process, but there are many options available to help manage symptoms, promote healing, and improve quality of life. While no moisture treatment is one controversial approach, it’s not the only path to recovery.

Working closely with a knowledgeable dermatologist to develop a personalized treatment plan that incorporates a combination of medical therapies, gentle skin care practices, and lifestyle modifications can help you navigate the ups and downs of TSW with greater confidence and resilience.

It’s important to be patient with the healing process and not expect overnight results. TSW can take months or even years to fully resolve, and setbacks and flares are a normal part of the journey. Celebrating small victories, practicing self-compassion, and leaning on your support network can help you stay motivated and hopeful along the way.

Remember, you are not alone in this journey. With time, patience, and the right support, it is possible to heal from TSW and regain your skin health and quality of life. Don’t hesitate to reach out for help when you need it, and trust in your body’s incredible capacity for healing and resilience.

Key Points

  • No moisture treatment (NMT) is a controversial approach to treating TSW that involves completely avoiding all sources of moisture to allow the skin to dry out and heal quickly.
  • NMT is based on the theory that moisturizers can interfere with the skin’s natural healing process and prolong TSW symptoms.
  • There is currently limited scientific evidence to support the effectiveness or safety of NMT for TSW, and it may not be appropriate for everyone.
  • Other treatment options for TSW include topical steroid tapering, gentle moisturization, wet wrap therapy, oral medications, and phototherapy.
  • Lifestyle strategies like stress reduction, itch management, skin infection prevention, and nutritional support can also help manage TSW symptoms and promote healing.
  • Finding support through online communities, in-person support groups, blogs/podcasts, and counseling can be invaluable for coping with the emotional challenges of TSW.
  • Healing from TSW is a highly individual process that requires patience, self-compassion, and a personalized approach to treatment under the guidance of a knowledgeable dermatologist.

Frequently Asked Questions

Is no moisture treatment safe for everyone with TSW?

No, NMT is not safe or appropriate for everyone with TSW. It can be very challenging and may increase the risk of complications like infections, dehydration, and skin damage. It should only be attempted under close medical supervision and may not be suitable for people with certain health conditions or skin types.

How long does it take to see results from TSW treatments?

The timeline for seeing results from TSW treatments varies widely from person to person. Some people may start to see improvements in their symptoms within a few weeks, while others may take several months or even years to fully heal. Factors that can impact healing time include the severity of TSW, the duration and potency of prior steroid use, age, overall health, and adherence to treatment.

Can diet cure TSW?

While there is no specific diet that can cure TSW, what you eat can play a role in supporting your skin health and overall well-being during the healing process. Focusing on nutrient-dense whole foods, staying hydrated, and avoiding potential trigger foods may help reduce inflammation and promote healing. However, diet alone is not a substitute for medical treatment and should be used in conjunction with other therapies under the guidance of a healthcare provider.

Are there any medications that can speed up TSW healing?

There is no single medication that can speed up the TSW healing process for everyone. However, certain medications like oral steroids, antihistamines, immunosuppressants, and antibiotics may be prescribed to help manage specific symptoms like inflammation, itch, or infection. The choice of medication will depend on the individual’s symptoms, health history, and response to treatment.

How can I find a dermatologist who understands TSW?

Finding a dermatologist who is knowledgeable about TSW can be challenging, but there are several resources that can help. You can start by asking for referrals from your primary care provider, searching online directories like the International Topical Steroid Awareness Network (ITSAN) or the National Eczema Association, or joining TSW support groups and asking for recommendations. When meeting with a new dermatologist, don’t hesitate to ask about their experience treating TSW and their approach to managing the condition.

References

  1. Sheary, B. (2018). Topical steroid addiction and withdrawal – An overview for GPs. Australian Family Physician, 47(5), 296-300. PMID: 29735821.
  2. Hajar, T., Leshem, Y. A., Hanifin, J. M., Nedorost, S. T., Lio, P. A., Paller, A. S., Block, J., & Simpson, E. L. (2015). A systematic review of topical corticosteroid withdrawal (“steroid addiction”) in patients with atopic dermatitis and other dermatoses. Journal of the American Academy of Dermatology, 72(3), 541-549.e2. doi: 10.1016/j.jaad.2014.11.024. PMID: 25592622.
  3. Juhász, M. L. W., Curley, R. A., Rasmussen, A., Malakouti, M., Silverberg, N., & Jacob, S. E. (2017). Systematic Review of the Topical Steroid Addiction and Topical Steroid Withdrawal Phenomenon in Children Diagnosed With Atopic Dermatitis and Treated With Topical Corticosteroids. Journal of the Dermatology Nurses’ Association, 9(5), 233-240. doi: 10.1097/JDN.0000000000000331.
  4. Fukaya, M., Sato, K., Sato, M., Kimata, H., Fujisawa, S., Dozono, H., Yoshizawa, J., & Minaguchi, S. (2014). Topical steroid addiction in atopic dermatitis. Drug, Healthcare and Patient Safety, 6, 131-138. doi: 10.2147/DHPS.S69201. PMID: 25378953; PMCID: PMC4207549.
  5. Ghosh, A., Sengupta, S., Coondoo, A., & Jana, A. K. (2014). Topical corticosteroid addiction and phobia. Indian Journal of Dermatology, 59(5), 465-468. doi: 10.4103/0019-5154.139876. PMID: 25284849; PMCID: PMC4171912.
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