Steroid Withdrawal Itching: What You Need to Know

May 27, 2024

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If you’ve been using topical corticosteroids to manage a skin condition like eczema or psoriasis, you may have experienced the frustrating and sometimes unbearable itching that can occur when you try to stop the medication. This intense itching, along with other symptoms like rednessburning, and flaking, is a hallmark of topical steroid withdrawal (TSW), also known as “steroid addiction” or “red skin syndrome.”

In this article, we’ll take a deep dive into the causes, symptoms, and management of steroid withdrawal itching and related skin symptoms. Whether you’re currently going through TSW or are considering tapering off your topical steroids, understanding what to expect and how to cope can help you navigate this challenging process.

What Causes Steroid Withdrawal Itching?

Topical corticosteroids are a class of medications that are commonly prescribed to treat inflammatory skin conditions like eczema (atopic dermatitis), psoriasis, and contact dermatitis[1]. These medications work by suppressing the immune system and reducing inflammation in the skin, which can help relieve symptoms like itching, redness, and flaking.

However, when topical steroids are used for prolonged periods (usually more than a few weeks), the skin can become “addicted” to their effects[1]. This means that the skin becomes dependent on the steroids to control inflammation and maintain its normal function. When the steroids are suddenly withdrawn or tapered too quickly, the skin can experience a rebound reaction, leading to intense itching and other TSW symptoms.

The exact mechanisms behind steroid withdrawal itch are not fully understood, but several factors are thought to contribute:

  • Increased skin inflammation: When topical steroids are discontinued, the skin’s natural inflammatory response can go into overdrive, leading to increased redness, swelling, and itching[1].
  • Disruption of the skin barrier: Long-term use of topical steroids can thin and damage the skin’s protective barrier, making it more susceptible to irritation, dryness, and itching[2].
  • Changes in nerve sensitivity: Topical steroids may alter the way that the skin’s sensory nerves respond to stimuli, leading to heightened sensitivity and itching when the medication is withdrawn[1].
  • Imbalance of natural moisturizing factors: Steroids can disrupt the skin’s production of natural oils and moisturizing factors, contributing to dryness and itching when they are discontinued[2].

It’s important to note that not everyone who uses topical steroids will develop TSW or experience severe itching when they stop the medication. However, certain factors may increase the risk, including:

  • Using high-potency steroids for extended periods
  • Applying steroids to sensitive areas like the face or genitals
  • Having a history of eczema or other inflammatory skin conditions
  • Abruptly stopping steroids rather than tapering gradually

If you’ve been using topical steroids and are concerned about the potential for withdrawal symptoms, it’s important to talk to your dermatologist before making any changes to your treatment plan.

Symptoms of Topical Steroid Withdrawal

Steroid withdrawal itching is often accompanied by a constellation of other skin symptoms that can range from mild to severe. These symptoms typically appear within days to weeks of discontinuing topical steroids and can persist for several months or even years in some cases.

Topical Steroid Withdrawal Rash

One of the most common and distressing symptoms of TSW is the steroid withdrawal rash, also known as “red skin syndrome” or “topical steroid-induced rosacea.” This rash is characterized by:

  • Bright red, flushed skin that may feel hot and burning
  • Intense itching that is often worse at night
  • Swelling and puffiness, especially on the face
  • Oozing and weeping of clear fluid from the skin
  • Crusting and flaking as the skin heals and regenerates

The rash often starts in the area where the topical steroid was applied but can spread to other parts of the body over time. It may be mistaken for an infection or allergic reaction at first, but it typically does not respond to antibiotics or antihistamines.

There are two main subtypes of the TSW rash:

  1. Erythematoedematous subtype: This is the most common presentation, characterized by red, swollen, and itchy skin that may have a “headlight” pattern on the face (redness and swelling around the eyes and nose)[1].
  2. Papulopustular subtype: This type of rash is characterized by small, red, pus-filled bumps (pustules) that can be itchy and painful. It is more common in people who used topical steroids for acne or rosacea[1].

Both types of rash can be extremely uncomfortable and emotionally distressing, leading to sleep disturbances, anxiety, and depression. Treatment typically involves supportive care with gentle cleansers and moisturizers, along with oral antihistamines or low-dose naltrexone to help manage the itch.

Topical Steroid Withdrawal Flaking

Another hallmark symptom of TSW is severe skin flaking and peeling, also known as “skin shedding” or “dermatitis exfoliativa.” This occurs as the damaged skin cells are rapidly replaced by new ones, leading to a cycle of flaking and regeneration that can last for several weeks or months.

The flaking in TSW is often described as:

  • Thick, moist flakes that may be yellow or oily in appearance
  • Fine, dry scales that shed constantly and can be triggered by friction or sweating
  • Large sheets of skin that peel off in one piece, revealing red, raw skin underneath

The severity of flaking can vary from person to person and may wax and wane over the course of the withdrawal process. Some people may experience only mild dryness and flaking, while others may shed skin in large amounts that can be messy and embarrassing.

Treatment of TSW flaking involves gentle skin care with emollients and moisturizers to help soothe and protect the skin. Lukewarm baths with colloidal oatmeal or other soothing additives can also help relieve itching and soften the flakes. It’s important to avoid picking or scrubbing at the flakes, as this can further irritate the skin and delay healing.

Other Symptoms of TSW

In addition to itching, rashing, and flaking, TSW can cause a range of other symptoms that can vary in severity and duration. These may include:

  • Burning and stinging sensations on the skin
  • Skin sensitivity and tenderness to the touch
  • Skin tightness and dryness, especially after bathing or showering
  • Skin discoloration, including redness, hyperpigmentation, and hypopigmentation
  • Skin thickening and lichenification (leathery texture) from chronic scratching
  • Skin atrophy (thinning) and fragility from prolonged steroid use
  • Edema (swelling) of the face, hands, and feet
  • Eye irritation and dryness, including conjunctivitis and blepharitis
  • Nail changes, such as ridging, pitting, and discoloration

TSW can also cause systemic symptoms that affect the whole body, such as:

  • Fatigue and weakness
  • Insomnia and sleep disturbances
  • Appetite changes and weight loss
  • Muscle and joint aches
  • Headaches and dizziness
  • Gastrointestinal issues, such as nausea, vomiting, and diarrhea
  • Psychological symptoms, such as anxiety, depression, and irritability

These symptoms can be incredibly challenging to deal with and can significantly impact quality of life. It’s important to work closely with a dermatologist who understands TSW and can provide appropriate support and treatment options.

Diagnosing Topical Steroid Withdrawal

Diagnosing TSW can be tricky because the symptoms can mimic those of other skin conditions, such as eczema, psoriasis, rosacea, and contact dermatitis. There is no specific test for TSW, so diagnosis relies on a thorough medical history and physical examination by a knowledgeable dermatologist.

Some key factors that suggest a diagnosis of TSW include:

  • History of prolonged topical steroid use, especially on the face or genital area
  • Worsening of skin symptoms within days to weeks of stopping the medication
  • Burning and stinging sensations that are out of proportion to the visible rash
  • Spreading of the rash to areas where the steroid was not originally applied
  • Failure to respond to usual treatments for eczema, psoriasis, or other skin conditions

Your dermatologist may also perform a skin biopsy to rule out other conditions that can cause similar symptoms, such as cutaneous T-cell lymphoma or fungal infections.

It’s important to find a dermatologist who is familiar with diagnosing and treating TSW, as many healthcare providers may not be aware of this condition or may misdiagnose it as an exacerbation of the original skin problem.

Managing Steroid Withdrawal Itching and Other Symptoms

The management of steroid withdrawal itching and other TSW symptoms depends on the severity of the condition and the individual needs of the patient. The primary goals of treatment are to relieve discomfort, support skin healing, and prevent complications.

Gentle Skin Care

One of the most important aspects of managing TSW is practicing gentle skin care to avoid further irritation and promote healing. This includes:

  • Using lukewarm water for bathing and showering, as hot water can dry out the skin and worsen itching
  • Applying fragrance-free, hypoallergenic moisturizers multiple times a day to help soothe and protect the skin barrier
  • Choosing gentle, non-foaming cleansers that won’t strip the skin of its natural oils
  • Patting the skin dry instead of rubbing with a towel
  • Wearing loose, breathable clothing made from soft, natural fibers like cotton or bamboo

Your dermatologist may also recommend specific moisturizers or barrier repair creams that are formulated for sensitive, eczema-prone skin.

Wet Wrap Therapy

For severe cases of TSW that involve extensive rashing and flaking, your dermatologist may recommend wet wrap therapy to help hydrate and soothe the skin. This involves applying a layer of moisturizer or medicated cream to the affected skin, then covering it with a layer of damp gauze or clothing (such as cotton pajamas or gloves) followed by a dry layer on top.

Wet wraps are typically left on for several hours or overnight and can be repeated daily or as needed. They can help:

  • Increase the penetration of moisturizer into the skin
  • Reduce inflammation and itching
  • Protect the skin from scratching and further irritation
  • Promote healing of cracked or oozing skin

It’s important to follow your dermatologist’s instructions carefully when using wet wraps, as overuse or improper technique can lead to skin maceration or infection.

Medications for Itch Relief

While there is no cure for TSW, several medications can help manage the intense itching and discomfort associated with the condition. These may include:

  • Oral antihistamines, such as diphenhydramine (Benadryl) or hydroxyzine (Atarax), which can help reduce itching and improve sleep
  • Topical calcineurin inhibitors, such as tacrolimus (Protopic) or pimecrolimus (Elidel), which are non-steroid medications that can help reduce inflammation and itching
  • Oral corticosteroids, such as prednisone, which may be used in severe cases to quickly reduce inflammation and itching (but should be used with caution due to potential side effects)
  • Gabapentin or pregabalin, which are medications that can help reduce nerve-related itching and pain
  • Low-dose naltrexone, which is an off-label treatment that has shown promise in reducing inflammation and itching in some TSW patients

Your dermatologist will work with you to determine which medications are appropriate for your individual case and monitor you closely for any side effects.

Phototherapy

For some people with TSW, phototherapy (also known as light therapy) can be a helpful adjunctive treatment to reduce inflammation and itching. The most common type of phototherapy used for TSW is narrowband UVB (NB-UVB), which involves exposing the skin to a specific wavelength of ultraviolet light.

NB-UVB phototherapy is typically performed in a dermatologist’s office or at a specialized phototherapy center, and requires multiple sessions per week for several weeks to see improvement. It can help:

  • Reduce inflammation in the skin
  • Decrease itching and discomfort
  • Promote healing of rashes and lesions
  • Improve sleep and quality of life

However, phototherapy may not be appropriate for everyone with TSW, especially those with very fair skin or a history of skin cancer. It can also have potential side effects, such as skin dryness, itching, and burning. Your dermatologist can help you determine if phototherapy is a good option for your individual case.

Stress Management and Coping Strategies

Managing the psychological impact of TSW is just as important as treating the physical symptoms. The constant itching, pain, and visible skin changes can be incredibly distressing and can lead to feelings of depression, anxiety, and social isolation.

Some strategies that may help you cope with the stress of TSW include:

  • Practicing relaxation techniques, such as deep breathing, meditation, or progressive muscle relaxation
  • Engaging in gentle exercise, such as yoga, tai chi, or walking, to help reduce stress and promote circulation
  • Seeking support from loved ones, friends, or a therapist who can provide a listening ear and practical help
  • Joining a support group for people with TSW, such as the ITSAN (International Topical Steroid Awareness Network) forum or social media groups
  • Focusing on self-care activities that bring you joy and comfort, such as reading, listening to music, or spending time in nature

Remember that healing from TSW is a gradual process, and it’s normal to have ups and downs along the way. Be patient with yourself and celebrate the small victories as your skin begins to heal.

When to Seek Medical Attention

While some itching and discomfort are to be expected during TSW, there are certain symptoms that warrant prompt medical attention. Contact your dermatologist or seek emergency care if you experience any of the following:

  • Signs of skin infection, such as sudden worsening of redness, swelling, pain, or oozing of pus
  • Fever or chills along with your skin symptoms
  • Severe swelling of the face, lips, or tongue that may indicate an allergic reaction
  • Difficulty breathing or swallowing
  • Suicidal thoughts or severe depression that interferes with your daily functioning

Your dermatologist can help you assess the severity of your symptoms and determine if additional treatment or referral to another specialist is necessary.

Preventing Steroid Withdrawal Itching and Other TSW Symptoms

The best way to prevent steroid withdrawal itching and other TSW symptoms is to use topical corticosteroids judiciously and under the close supervision of a dermatologist. Some tips for minimizing your risk of developing TSW include:

  • Using the lowest potency steroid needed to control your symptoms, for the shortest duration possible
  • Applying a thin layer of the steroid only to affected areas of skin, not to healthy skin
  • Following your dermatologist’s instructions for frequency and duration of use
  • Avoiding long-term use of topical steroids on sensitive areas, such as the face, genitals, and skin folds
  • Monitoring for signs of skin thinning, easy bruising, or stretch marks, which can indicate overuse of topical steroids
  • Using non-steroid treatments, such as moisturizers and topical calcineurin inhibitors, to help control eczema symptoms and reduce the need for topical steroids

If you have been using topical steroids for a long time and are concerned about the risk of withdrawal, talk to your dermatologist about developing a personalized plan for tapering off the medication safely.

The Bottom Line

Steroid withdrawal itching and other symptoms of TSW can be incredibly challenging and distressing to deal with, but with proper medical guidance and support, it is possible to get through the withdrawal process and achieve healthier, more resilient skin.

If you suspect that you may be experiencing TSW, don’t hesitate to reach out to a dermatologist who is knowledgeable about this condition. They can help you develop a personalized treatment plan that addresses your specific symptoms and concerns.

Remember, everyone’s journey with TSW is unique, and what works for one person may not work for another. Be patient with yourself and your skin, and don’t hesitate to seek support from loved ones, healthcare providers, and the TSW community as you navigate this challenging process.

Key Points

  • Steroid withdrawal itching is a common and often severe symptom of topical steroid withdrawal (TSW), a condition that can occur when topical corticosteroids are stopped after prolonged use.
  • Other symptoms of TSW include a red, burning rash, severe flaking and peeling, swelling, and oozing.
  • The exact mechanisms of steroid withdrawal itch are not fully understood, but may involve increased skin inflammation, disruption of the skin barrier, and changes in nerve sensitivity.
  • Diagnosis of TSW relies on a thorough medical history and physical examination by a knowledgeable dermatologist, as there is no specific test for the condition.
  • Treatment of steroid withdrawal itching and other TSW symptoms typically involves gentle skin care, medications to control itch and inflammation, and stress management techniques.
  • Phototherapy and wet wrap therapy may be helpful for some people with severe or persistent TSW symptoms.
  • The psychological impact of TSW can be significant, and it’s important to seek support from loved ones, healthcare providers, and the TSW community.
  • Preventing TSW involves using topical steroids judiciously, under the guidance of a dermatologist, and monitoring for signs of overuse.
  • If you suspect you may be experiencing TSW, seek evaluation and guidance from a knowledgeable dermatologist.

Frequently Asked Questions

How long does steroid withdrawal itching last?

The duration of steroid withdrawal itching varies from person to person, but it can persist for several weeks to several months after stopping topical steroids. In some cases, the itching may come and go for a year or more. Working closely with a dermatologist and following a gentle skin care routine can help manage the itch and promote healing.

Can I use over-the-counter anti-itch creams for steroid withdrawal itching?

Over-the-counter anti-itch creams, such as those containing hydrocortisone or pramoxine, are generally not recommended for steroid withdrawal itching. These creams may provide temporary relief, but they can also further irritate the skin and prolong the withdrawal process. It’s best to consult with your dermatologist about safe and effective options for managing TSW itch.

Is steroid withdrawal itching contagious?

No, steroid withdrawal itching is not contagious. It is a reaction to the discontinuation of topical corticosteroids and cannot be spread from person to person.

Can diet affect steroid withdrawal itching?

While there is no specific “steroid withdrawal diet,” some people find that certain foods may trigger or worsen their symptoms. Common culprits include dairy, gluten, sugar, and processed foods. Keeping a food diary and working with a registered dietitian may help identify potential triggers. However, dietary changes alone are unlikely to resolve steroid withdrawal itching.

Are there any natural remedies for steroid withdrawal itching?

Some people find relief from steroid withdrawal itching with natural remedies, such as colloidal oatmeal baths, aloe vera gel, or coconut oil. However, it’s important to talk to your dermatologist before trying any new treatments, as some natural remedies may actually worsen your symptoms or interact with your prescribed medications. Your dermatologist can help you determine which remedies may be safe and effective for your individual case.

If you’re struggling with steroid withdrawal itching or other symptoms of TSW, know that you’re not alone. With the right medical guidance, self-care strategies, and support from loved ones and the TSW community, it is possible to get through this challenging time and emerge with healthier, more resilient skin. Don’t hesitate to reach out for help when you need it, and remember to be kind to yourself as you navigate the ups and downs of the healing process.

References

  1. Sheary, B. (2018). Topical steroid addiction and withdrawal-An overview for GPs. Australian family physician, 47(10), 668-671.&
  2. Hajar, T., Leshem, Y. A., Hanifin, J. M., Nedorost, S. T., Lio, P. A., Paller, A. S., … & 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.
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