Protopic Withdrawal: What You Need to Know

July 1, 2024

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If you’ve been using Protopic (tacrolimus) ointment to manage eczema or another inflammatory skin condition, you may have questions about the potential for Protopic withdrawal symptoms when stopping the medication. Protopic is a topical calcineurin inhibitor that works differently than topical corticosteroids to treat eczema, but some people report developing symptoms similar to topical steroid withdrawal (TSW) after discontinuing Protopic.

In this article, we’ll take an in-depth look at what Protopic withdrawal is, how it compares to topical corticosteroid withdrawal, and what symptoms to watch for. We’ll discuss the risk factors for developing withdrawal symptoms and explore treatment options to help manage symptoms and support skin healing. Most importantly, we’ll emphasize the importance of working closely with a dermatologist when starting or stopping any topical medication for eczema.

Whether you’re currently using Protopic, considering it as a treatment option, or experiencing symptoms after stopping it, this article will provide the information you need to make informed decisions about your skin health. Let’s dive in.

What is Protopic?

Protopic (tacrolimus) ointment is a topical medication used to treat moderate to severe atopic dermatitis (eczema) in adults and children who have not responded well to other treatments[1]. It belongs to a class of drugs called topical calcineurin inhibitors (TCIs), which work by suppressing the immune system in the skin to reduce inflammation and itching.

Protopic is available in two strengths: 0.03% and 0.1%. The 0.03% strength is approved for use in children aged 2-15 years, while the 0.1% strength is for adults and children over 15 years old. It is typically applied as a thin layer to affected areas of skin twice daily until symptoms improve, and then used intermittently to prevent flares.

Unlike topical corticosteroids, Protopic does not carry the same risks of skin thinning, pigment changes, or systemic absorption with long-term use. This makes it an attractive alternative for people with eczema who need ongoing treatment, especially on delicate areas like the face and eyelids.

However, Protopic can cause some side effects, such as burning, stinging, and itching at the application site, especially during the first few days of use. It may also increase the risk of skin infections and, rarely, skin cancer and lymphoma, although the causal relationship is not clear[2].

How Does Protopic Compare to Topical Corticosteroids?

Topical corticosteroids are the mainstay of treatment for eczema and other inflammatory skin conditions. They work by binding to glucocorticoid receptors in the skin to reduce inflammation, itching, and redness. Topical steroids come in various strengths, from mild over-the-counter hydrocortisone to very potent prescription creams like clobetasol.

While topical steroids are generally safe and effective when used as directed, prolonged or frequent use of mid- to high-potency steroids can lead to side effects like:

  • Skin thinning (atrophy)
  • Stretch marks (striae)
  • Pigment changes
  • Easy bruising
  • Increased hair growth
  • Acne or rosacea
  • Topical steroid withdrawal (TSW) symptoms when stopped

Protopic, on the other hand, works by inhibiting the activity of calcineurin, an enzyme that activates inflammatory cells in the skin. This reduces inflammation and itching without the same risks of skin thinning and other steroid-related side effects.

Studies have shown that Protopic is as effective as mid-potency topical steroids for controlling eczema symptoms, with a lower risk of side effects[3]. It can be used long-term as a steroid-sparing agent to minimize the need for topical steroids and their potential complications.

However, Protopic is not without its own risks and side effects. The most common are application site reactions like burning, stinging, and itching, which usually subside with continued use. Protopic may also increase the risk of skin infections, particularly herpes simplex virus (HSV) and molluscum contagiosum[4].

Rarely, cases of skin cancer and lymphoma have been reported in people using Protopic, although a causal link has not been established[2]. As a precaution, the FDA recommends limiting sun exposure and using sun protection while using Protopic.

What is Protopic Withdrawal?

Protopic withdrawal refers to a constellation of symptoms that can occur when stopping Protopic treatment after prolonged use. These symptoms can resemble those of topical steroid withdrawal, with a rebound of eczema symptoms that may be more severe than before starting treatment.

The exact mechanism of Protopic withdrawal is not well understood, but it is thought to involve a rebound of inflammation in the skin when the immunosuppressive effects of the medication are removed. This may be due to changes in the skin’s immune system and barrier function over time with prolonged Protopic use.

Symptoms of Protopic withdrawal can include[5]:

  • Redness and flushing of the skin
  • Burning and stinging sensations
  • Intense itching
  • Skin dryness and flaking
  • Oozing and crusting of the skin
  • Swelling (edema) of the affected areas
  • Spread of rash to previously unaffected areas

These symptoms usually develop within days to weeks of stopping Protopic and can last for several weeks to months. In some cases, they may be severe enough to interfere with sleep, daily activities, and quality of life.

It’s important to note that not everyone who uses Protopic will experience withdrawal symptoms when stopping it. The risk appears to be higher in people who have used Protopic continuously for longer periods (e.g., more than a year), especially at higher strengths or over large areas of the body.

If you are considering stopping Protopic or are experiencing symptoms after recently stopping it, it’s important to speak with your dermatologist for guidance on managing the withdrawal process and treating any rebound symptoms.

Protopic Withdrawal vs. Topical Steroid Withdrawal

While Protopic withdrawal and topical steroid withdrawal (TSW) can cause similar symptoms, there are some key differences between these two conditions.

TSW is a well-documented phenomenon that can occur when topical corticosteroids are used for prolonged periods and then abruptly stopped or rapidly tapered. It is thought to result from the skin’s dependence on the anti-inflammatory effects of the steroids, leading to a rebound of inflammation when they are withdrawn[6].

Symptoms of TSW can include:

  • Red, burning, and itchy skin
  • Oozing and crusting
  • Skin peeling and flaking
  • Swelling and redness
  • Spread of rash to new areas
  • Severe itching and sleep disturbance

These symptoms can persist for weeks to months after stopping topical steroids and can be very distressing and disruptive to daily life. TSW is more likely to occur with higher potency steroids used for longer durations, especially on the face and genital area.

In contrast, Protopic withdrawal seems to be less common and less severe than TSW. While the symptoms can be similar, they tend to be milder and shorter-lived than those of TSW[5]. This may be because Protopic works differently than steroids and does not cause the same degree of skin atrophy and barrier dysfunction with long-term use.

However, more research is needed to fully understand the mechanisms and risk factors for Protopic withdrawal. Some studies have suggested that people with a history of TSW may be more susceptible to developing withdrawal symptoms with Protopic[7], but this has not been definitively proven.

Regardless of whether you are using topical steroids or Protopic, it’s important to use these medications judiciously and under the guidance of a dermatologist. Avoid using them continuously for prolonged periods without breaks, and follow your doctor’s instructions for tapering or stopping treatment to minimize the risk of withdrawal reactions.

Diagnosing Protopic Withdrawal

Diagnosing Protopic withdrawal can be challenging, as the symptoms can mimic those of a severe eczema flare or other skin conditions like contact dermatitis or psoriasis. There is no specific test or biomarker for Protopic withdrawal, so the diagnosis is typically made based on a combination of clinical history, physical examination, and ruling out other potential causes.

If you suspect you may be experiencing Protopic withdrawal, the first step is to make an appointment with your dermatologist. During your visit, your doctor will likely ask you detailed questions about your skin health history, including:

  • How long you have been using Protopic and at what strength
  • How often you apply Protopic and to what areas of the body
  • When you stopped using Protopic and how quickly you tapered off
  • What symptoms you are currently experiencing and when they started
  • Any other medications, topical products, or treatments you use
  • Your history of eczema, TSW, or other skin conditions
  • Any other health conditions or allergies you may have

Your dermatologist will also perform a thorough skin examination to assess the extent and severity of your symptoms. They may take photos to document your skin’s appearance and monitor changes over time.

In some cases, your doctor may recommend additional tests to rule out other potential causes of your symptoms, such as:

  • Skin biopsy: A small sample of skin may be taken and examined under a microscope to look for signs of skin inflammation, infection, or other abnormalities. However, the histologic findings of Protopic withdrawal are often nonspecific and may resemble those of eczema or psoriasis.
  • Patch testing: If contact dermatitis is suspected, your doctor may apply small amounts of potential allergens to your skin to see if they trigger a reaction. This can help identify any topical products or ingredients that may be contributing to your symptoms.
  • Culture and sensitivity: If a skin infection is suspected, your doctor may take a sample of pus or skin cells and send it to a lab to identify the causative organism and determine the best antibiotic treatment.

Once other potential causes have been ruled out, your doctor may diagnose you with Protopic withdrawal based on your clinical history and the characteristic skin findings. They will work with you to develop a personalized treatment plan to manage your symptoms and support skin healing.

Treating Protopic Withdrawal

The primary treatment for Protopic withdrawal is time and supportive care to allow the skin to heal and adjust to the absence of the medication. This process can take several weeks to months, depending on the severity of your symptoms and the duration of your Protopic use.

During this time, your dermatologist may recommend a combination of the following strategies to manage your symptoms and promote skin healing:

Gentle Skin Care

One of the most important things you can do during Protopic withdrawal is to practice gentle, non-irritating skin care. This includes:

  • Using lukewarm water and mild, fragrance-free cleansers when washing
  • Patting the skin dry gently instead of rubbing
  • Applying a thick, fragrance-free emollient or ointment to lock in moisture
  • Avoiding hot showers, harsh soaps, and irritating skincare products
  • Wearing loose, soft, breathable clothing to minimize friction and irritation

Your dermatologist can recommend specific products that are safe and effective for sensitive, eczema-prone skin.

Wet Wraps

Applying topical medications or moisturizers under a layer of damp gauze or clothing, known as wet wrapping, can help soothe and hydrate the skin during Protopic withdrawal. Wet wraps provide a physical barrier against scratching and can enhance the absorption of topical products.

To use wet wraps, follow these steps:

  1. Take a lukewarm bath or shower and pat the skin dry gently.
  2. Apply a thick layer of moisturizer or prescribed medication to the affected areas.
  3. Dampen a piece of gauze or soft clothing with lukewarm water and wrap it around the affected area.
  4. Cover the damp layer with a dry layer of clothing or gauze.
  5. Leave the wraps on for several hours or overnight, then gently remove and moisturize the skin again.

Be sure to use clean wraps for each application and watch for signs of skin infection, such as increased redness, swelling, or oozing.

Topical Medications

While Protopic should be avoided during the withdrawal process, your dermatologist may prescribe other topical medications to help manage your symptoms and prevent complications. These may include:

  • Topical corticosteroids: In some cases, a short course of low-potency topical steroids may be used to control inflammation and itching during the acute phase of withdrawal. However, this should be done cautiously and under close medical supervision to avoid exacerbating TSW symptoms.
  • Topical antibiotics: If a secondary skin infection develops, topical antibiotics like mupirocin or fusidic acid may be prescribed to clear the infection and prevent it from spreading.
  • Topical anti-itch medications: Over-the-counter or prescription creams and lotions containing menthol, camphor, pramoxine, or capsaicin may help relieve itching and discomfort.

Your dermatologist will work with you to find the most appropriate topical treatments for your individual needs and monitor your skin’s response.

Oral Medications

In more severe cases of Protopic withdrawal, your dermatologist may prescribe oral medications to help control symptoms and support the healing process. These may include:

  • Oral antihistamines: Non-sedating antihistamines like cetirizine or fexofenadine can help reduce itching and inflammation. Sedating antihistamines like diphenhydramine or hydroxyzine may be used at night to improve sleep.
  • Oral antibiotics: If a widespread or severe skin infection develops, oral antibiotics like cephalexin or dicloxacillin may be needed to clear the infection and prevent sepsis.
  • Oral corticosteroids: In rare cases, a short course of oral corticosteroids like prednisone may be prescribed to rapidly control severe inflammation and itching. However, this should be used with extreme caution and only under close medical supervision, as it can worsen TSW symptoms and lead to adrenal suppression.

Your dermatologist will discuss the potential risks and benefits of oral medications with you and monitor you closely for any adverse effects.

Phototherapy

Phototherapy, or controlled exposure to ultraviolet (UV) light, has been shown to have anti-inflammatory and immunomodulatory effects on the skin. It may be helpful for managing the symptoms of Protopic withdrawal and promoting skin healing.

The most common types of phototherapy used for eczema and TSW are:

  • Narrowband UVB: This uses a specific wavelength of UVB light (311-313 nm) that is less likely to cause skin damage than broadband UVB. It is typically administered 2-3 times per week in a dermatologist’s office or phototherapy center.
  • UVA1: This uses a longer wavelength of UV light (340-400 nm) that can penetrate deeper into the skin than UVB. It is thought to have more potent anti-inflammatory effects and may be particularly helpful for acute, severe flares of eczema or TSW.

Phototherapy is usually done in a series of treatments over several weeks to months, with the dose of UV light gradually increased as tolerated. It can be an effective adjunctive treatment for Protopic withdrawal, but it may not be appropriate for everyone. Risks include skin burning, aging, and a slightly increased risk of skin cancer with long-term use.

Your dermatologist can help you determine if phototherapy is a good option for your specific case and refer you to a qualified phototherapy center.

Lifestyle Modifications

In addition to medical treatments, there are several lifestyle modifications that can help support skin healing and overall well-being during Protopic withdrawal:

  • Stress management: Stress is a common trigger for eczema and can exacerbate TSW symptoms. Engaging in stress-reducing activities like deep breathing, meditation, yoga, or exercise can help promote relaxation and reduce inflammation.
  • Sleep hygiene: Getting enough quality sleep is crucial for skin healing and overall health. Establish a regular sleep schedule, create a cool, dark, and comfortable sleep environment, and avoid stimulating activities before bedtime.
  • Moisturization: Keeping the skin well-hydrated is essential for reducing inflammation, itching, and flaking during Protopic withdrawal. Apply a thick, fragrance-free emollient or ointment several times a day, especially after bathing or showering.
  • Avoiding triggers: Identify and avoid personal triggers that can worsen eczema or TSW symptoms, such as certain foods, environmental allergens, or irritants. Keep a symptom diary to help track potential triggers.
  • Nutritional support: Eating a balanced, nutrient-rich diet can help support skin health and overall well-being. Focus on whole, unprocessed foods and consider supplementing with omega-3 fatty acids, vitamin D, and probiotics under the guidance of a healthcare provider.

Remember, the healing process from Protopic withdrawal is highly individualized and can take time. Be patient with yourself and your skin, and don’t hesitate to reach out to your dermatologist or a support group for guidance and encouragement.

Coping with the Emotional Impact of Protopic Withdrawal

Dealing with the physical symptoms of Protopic withdrawal can be challenging enough, but the emotional impact can be just as significant. Many people with TSW or Protopic withdrawal experience feelings of frustration, anxiety, depression, and social isolation due to their skin’s appearance and the constant discomfort.

It’s important to remember that these feelings are valid and understandable given the challenges of living with a chronic skin condition. You are not alone in your struggles, and there is no shame in seeking support for your mental health.

Here are some strategies that may help you cope with the emotional impact of Protopic withdrawal:

Seek Professional Support

Consider working with a mental health professional who can provide guidance and support throughout your withdrawal journey. A therapist or counselor can help you develop coping strategies, process your emotions, and address any underlying mental health concerns.

Look for a provider who has experience working with people with chronic skin conditions or chronic illness. They may offer in-person or virtual sessions, depending on your preferences and location.

Connect with Others

Joining a support group or online community for people with eczema, TSW, or Protopic withdrawal can be a valuable source of information, encouragement, and validation. Connecting with others who understand your experiences firsthand can help reduce feelings of isolation and provide a sense of belonging.

The National Eczema Association offers a variety of support services, including an online forum, local support groups, and educational resources. They also host an annual conference where you can connect with others in the eczema community.

Practice Self-Care

Engaging in regular self-care activities can help reduce stress, improve mood, and promote overall well-being. Some self-care strategies to consider:

  • Mindfulness and relaxation techniques: Practicing deep breathing, meditation, or progressive muscle relaxation can help calm the mind and body and reduce stress-related inflammation.
  • Gentle movement: Engaging in low-impact exercise like walking, stretching, or yoga can help reduce stress, improve circulation, and promote relaxation. Listen to your body and avoid activities that cause pain or irritation.
  • Hobbies and creative outlets: Engaging in activities that bring you joy and fulfillment can help distract from symptoms and promote a sense of accomplishment. Consider pursuits like reading, writing, drawing, or listening to music.
  • Social connections: Maintaining relationships with supportive friends and family members can provide a sense of connection and reduce feelings of isolation. Be open and honest about your needs and limitations.
  • Rest and relaxation: Prioritizing rest and relaxation can help reduce stress and promote healing. Take breaks throughout the day, practice good sleep hygiene, and engage in soothing activities like taking a warm bath or listening to calming music.

Practice Self-Compassion

Living with Protopic withdrawal can be a challenging and unpredictable journey. It’s important to practice self-compassion and be kind to yourself during this time. Some ways to cultivate self-compassion:

  • Acknowledge your feelings: Allow yourself to feel and express your emotions without judgment. It’s okay to have difficult days and to feel frustrated, sad, or angry at times.
  • Avoid self-blame: Remember that Protopic withdrawal is not your fault and is not a reflection of your worth as a person. You are doing the best you can with the challenges you face.
  • Celebrate small victories: Acknowledge and celebrate the small steps forward in your healing journey, no matter how insignificant they may seem. Each day of perseverance is a testament to your strength and resilience.
  • Seek support: Reach out to trusted friends, family members, or healthcare providers when you need encouragement, validation, or practical assistance. You don’t have to face Protopic withdrawal alone.
  • Practice gratitude: Focus on the positive aspects of your life and the things you are grateful for, no matter how small. Keeping a gratitude journal can help shift your focus away from your symptoms and toward the good in your life.

Remember, healing from Protopic withdrawal is a journey, not a destination. There will be ups and downs along the way, and progress may not always be linear. Be patient and compassionate with yourself, and trust that with time and proper care, your skin and your emotional well-being will improve.

If you are experiencing severe or persistent symptoms of depression, anxiety, or suicidal thoughts, please reach out for professional help immediately. You can contact the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or visit their website at https://suicidepreventionlifeline.org/ for 24/7 support and resources.

Conclusion

Protopic withdrawal is a potential side effect of prolonged Protopic use that can cause symptoms similar to those of topical steroid withdrawal. While not as well-studied as TSW, Protopic withdrawal can still be a challenging and distressing experience for those who go through it.

If you are experiencing symptoms of Protopic withdrawal, know that you are not alone and that there is hope for healing. Working closely with a knowledgeable and compassionate dermatologist is key to developing a personalized treatment plan that addresses your specific needs and goals.

In addition to medical treatments like topical and oral medications, phototherapy, and wet wraps, lifestyle modifications like stress management, gentle skin care, and trigger avoidance can also play an important role in supporting skin healing and overall well-being.

Remember to be patient and kind to yourself during the healing process, as it can take time for the skin to adjust to life without Protopic. Celebrate your progress, no matter how small, and don’t hesitate to reach out for support when needed.

While the journey of Protopic withdrawal can be challenging, know that with proper care and support, it is possible to achieve healthy, resilient skin and an improved quality of life. Trust in your body’s ability to heal, and never lose sight of the hope for a brighter future.

Key Takeaways

  • Protopic (tacrolimus) ointment is a topical calcineurin inhibitor used to treat eczema and other inflammatory skin conditions. It works differently than topical corticosteroids but can still cause withdrawal symptoms in some people.
  • Symptoms of Protopic withdrawal can include redness, burning, itching, and oozing of the skin, similar to those of topical steroid withdrawal (TSW). However, Protopic withdrawal is generally less common and severe than TSW.
  • The risk of Protopic withdrawal appears to be higher in people who have used the medication continuously for long periods, especially at higher strengths or over large areas of the body.
  • Diagnosis of Protopic withdrawal is based on clinical history, physical examination, and ruling out other potential causes of symptoms. There is no specific test for the condition.
  • Treatment of Protopic withdrawal involves discontinuing the medication, gentle skin care, wet wraps, topical and oral medications, phototherapy, and lifestyle modifications to support skin healing and manage symptoms.
  • The emotional impact of Protopic withdrawal can be significant, and seeking support from healthcare providers, mental health professionals, and the eczema community can be valuable for coping with the challenges of the condition.
  • Healing from Protopic withdrawal is a gradual and individualized process that requires patience, self-compassion, and a personalized approach to treatment.
  • Working closely with a dermatologist and practicing self-care can help promote skin healing, reduce symptoms, and improve quality of life during the withdrawal process.

FAQs

How long does Protopic withdrawal last?

The duration of Protopic withdrawal varies from person to person and depends on factors such as the strength and duration of Protopic use, individual skin characteristics, and overall health. Some people may experience symptoms for a few weeks, while others may have symptoms that persist for several months. On average, the healing process can take anywhere from 4 weeks to 3 months or longer.

Can I use topical corticosteroids during Protopic withdrawal?

In general, it is best to avoid using topical corticosteroids during Protopic withdrawal, as they can potentially worsen or prolong symptoms. However, in some cases, a short course of low-potency topical steroids may be used under close medical supervision to help control severe inflammation and itching. Always consult with your dermatologist before using any new topical medications during the withdrawal process.

Is Protopic withdrawal contagious?

No, Protopic withdrawal is not contagious. It is an individual reaction that occurs in the body in response to stopping the medication and cannot be spread from person to person.

Can diet affect Protopic withdrawal?

While there is no specific diet that has been proven to cure or prevent Protopic withdrawal, some people find that making certain dietary changes can help support skin healing and reduce inflammation during the withdrawal process. This may include avoiding trigger foods, eating a nutrient-dense diet, and staying hydrated. However, it’s important to work with a healthcare provider or registered dietitian before making significant changes to your diet, as individual nutritional needs and sensitivities can vary.

Will my skin return to normal after Protopic withdrawal?

Most people who go through Protopic withdrawal do experience significant improvement in their skin over time. However, the healing process can be gradual, and some people may have lingering changes in skin texture, color, or sensitivity. Working closely with a dermatologist and practicing good skin care habits can help promote optimal skin health and minimize the risk of long-term complications.

References

  1. Paller, A. S., Lebwohl, M., Fleischer, A. B., Antaya, R., Langley, R. G., Kirsner, R. S., Blum, R. R., Rico, M. J., Jaracz, E., Crowe, A., & Linowski, G. J. (2005). Tacrolimus ointment is more effective than pimecrolimus cream with a similar safety profile in the treatment of atopic dermatitis: results from 3 randomized, comparative studies. Journal of the American Academy of Dermatology, 52(5), 810-822. https://doi.org/10.1016/j.jaad.2004.12.038
  2. Siegfried, E. C., Jaworski, J. C., & Hebert, A. A. (2013). Topical calcineurin inhibitors and lymphoma risk: evidence update with implications for daily practice. American Journal of Clinical Dermatology, 14(3), 163-178. https://doi.org/10.1007/s40257-013-0020-1
  3. Doss, N., Reitamo, S., Dubertret, L., Fekete, G. L., Kamoun, M. R., Lahfa, M., Ortonne, J. P., Placchi, M., Brault, Y., & Clouet, J. (2009). Superiority of tacrolimus 0.1% ointment compared with fluticasone 0.005% in adults with moderate to severe atopic dermatitis of the face: results from a randomized, double-blind trial. The British Journal of Dermatology, 161(2), 427-434. https://doi.org/10.1111/j.1365-2133.2009.09143.x
  4. Luger, T., Boguniewicz, M., Carr, W., Cork, M., Deleuran, M., Eichenfield, L., Eigenmann, P., Fölster-Holst, R., Chen Hwang, S. T., Gelmetti, C., Gollnick, H., Kataoka, Y., Kragballe, K., Marcoux, D., Mortz, C. G., Murrell, D., Nakahara, T., Nasr, I., Nograles, K., Ohya, Y., … Vestergaard, C. (2015). Pimecrolimus in atopic dermatitis: consensus on safety and the need to allow use in infants. Pediatric Allergy and Immunology, 26(4), 306-315. https://doi.org/10.1111/pai.12331
  5. Fukaya, M., Sato, K., Yamada, T., Sato, M., Fujisawa, S., Minaguchi, S., Kimata, H., & Dozono, H. (2014). A prospective study of atopic dermatitis managed without topical corticosteroids for a 6-month period. Clinical, Cosmetic and Investigational Dermatology, 7, 151-158. https://doi.org/10.2147/CCID.S62337
  6. 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. https://doi.org/10.1016/j.jaad.2014.11.024
  7. 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. https://doi.org/10.2147/DHPS.S69201
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