Topical Steroid Withdrawal: Dupixent as a Potential Solution

June 26, 2024

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Topical steroid withdrawal (TSW) has recently gained more attention as a potential complication of long-term, potent topical steroid use. However, awareness and understanding of TSW still remains limited, even among medical professionals.

This article provides a comprehensive overview of topical steroid withdrawal, including its symptoms, causes, risk factors, and relationship to medications like dupixent. We’ll explore what TSW looks like, why it happens, and key considerations in management. Guidance is grounded in the latest evidence while prioritizing the patient perspective.

What Exactly is Topical Steroid Withdrawal?

Topical steroid withdrawal describes a cluster of symptoms that can occur when long-term use of topical steroids is abruptly stopped. It likely stems from adrenal suppression and skin barrier dysfunction.

Hallmark features of TSW include:

  • Red, inflamed skin
  • Intense burning and stinging sensations
  • Severe itchiness
  • Scaling, cracking, weeping skin
  • Swelling and flaking, especially on hands and feet

Symptoms typically onset within days to weeks of discontinuing topical steroids and can persist for months or years. The severity and duration depends on factors like strength of steroids used and duration of application.

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What Does TSW Look Like?

Topical steroid withdrawal can affect all areas previously treated with steroids but most prominently impacts flexural regions. Common sites include the:

  • Face
  • Neck
  • Armpits
  • Groin
  • Bends of arms/legs

The skin takes on a diffuse red appearance described as “red burning skin” or “red sleeve”. Other visible signs include:

  • Flaking, cracked skin with serous exudate
  • Swelling and eczema-like changes
  • Hives or itchy red bumps

There can also be accompanying symptoms of hair loss, eye issues, infections, and insomnia.

Key Causes and Risk Factors

The underlying trigger for TSW is stopping steroids after prolonged regular usage, but additional factors raise risk. These include:

Potency and Duration of Steroid Use

  • Using high potency topical steroids for more than 2 weeks consecutively
  • Using moderate potency for longer than 3 months
  • Low potency for longer than 6 months

Sites of Application

Areas like armpits, groin, and neck folds have enhanced absorption and increased susceptibility.

Age and Health Status

Those under 18 or over 65 seem most vulnerable. Concurrent health issues also raise risk.

Prior TSW Episodes

Having previously experienced TSW means the next episode will likely arrive faster and be more severe.

Abrupt Discontinuation

Suddenly stopping steroids “cold turkey” makes TSW more likely than slowly weaning off use.

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Why Does Topical Steroid Withdrawal Occur?

While the exact mechanisms still need clarification, two key processes likely drive the inflammation and symptomology of TSW:

Disruption of the Hypothalamic-Pituitary-Adrenal (HPA) Axis

Long-term topical steroid use can suppress endogenous cortisol production. Rapidly stopping leads to a deficiency in the body’s natural anti-inflammatories.

The hypothalamus and pituitary gland sense this deficit and try to urgently stimulate cortisol production. But the adrenal glands remain impaired from inhibition during steroid use.

Skin Barrier Dysfunction

Frequent steroid use impacts lipid production and impedes skin barrier repair. This heightens vulnerability to external irritants and infectious agents.

Combined dysfunction in the HPA axis and skin barrier converge to generate the profound redness, irritation, and inflammation of TSW.

Special Considerations by Body Area

While TSW can technically occur anywhere on the body, certain sites see heightened symptoms.

Face

Facial skin readily absorbs topical treatments but has overall thinner dermis. This means potent steroids applied to the face have higher likelihood of adrenal axis suppression.

Common TSW signs on the face consist of red cheeks, burning around the mouth and eyes, scaling across the forehead and chin. Swelling of the eyelids, lips and nose frequently occur as well.

Scalp

The scalp has abundant blood flow allowing for fast absorption of topical treatments. Hair follicles serve as extra reservoirs for steroids leading to enhanced suppression.

During TSW, the scalp turns intensely red and sheds white flakes. Hair thinning or loss is common. There can be marked sensitivity over the entire scalp.

Hands and Feet

The skin of hands and feet lacks hair follicles yet is relatively thick at up to 4mm in depth. But constant washing and friction enhances absorption of any steroid creams applied.

TSW symptoms largely concentrate on the sides/tips of fingers and tops of feet. Effects include red peeling skin, cracks/fissures, and painful inflammation with everyday movement.

Body site considerations provide unique expression but share the common underpinning of TSW pathogenesis.

Role of Dupixent (Dupilumab) for Treatment

Dupixent is a newer injectable biologic medication used mainly for atopic dermatitis and asthma. It blocks interleukin receptors to reduce inflammation.

But might Dupixent also help resolve symptoms of those suffering topical steroid withdrawal? Emerging evidence suggests potential benefit.

A 2018 case series followed 4 patients with severe, refractory TSW treated with Dupixent. All experienced marked improvement in inflammation, skin hardness, and pain levels within 1 month. Effects lasted through 6 months of therapy with enhanced ability to taper other systemic immunosuppressants.

Authors concluded Dupixent shows promise for managing TSW, perhaps by re-balancing immune dysregulation underlying the condition. More expanded trials are still needed though.

In another report, a 12 year old developed TSW after using topical steroids for 3 years to control atopic dermatitis. Standard treatments failed to relieve the severe burning, redness and itching so Dupixent was initiated.

Over 6 weeks the child had near complete resolution of TSW symptoms. Additionally, small studies demonstrate Dupixent enables restoring skin barrier function. By indirectly addressing key drivers like disrupted immunity and barrier defects, the drug may offer multi-modal relief.

However patients and providers should note Dupixent isn’t yet FDA approved specifically for TSW. And the treatment is expensive, costing over $30,000 annually without insurance coverage. Still, its benefits might outweigh challenges for moderate-severe cases.

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Specialist Perspectives on Management

With TSW still being newly characterized in the medical community, most guidelines remain generalized. But insights from leading specialists provide more exact direction:

Start Steroid Withdrawal Carefully

Don’t abruptly stop if using potent or moderate strength steroids for longer than 2-4 weeks. Slowly tapering under medical guidance is best.

Expect Symptoms Within 1-4 Weeks

Stay vigilant for TSW onset as soon as within a few weeks of tapering steroids. Early supportive care can greatly reduce complications.

Prioritize Gentle Care of Raw Skin

Frequently applying non-fragranced moisturizers and avoiding irritants/friction minimizes discomfort until skin stabilizes.

Consider Phototherapy

Options like narrow band UVB light therapy might effectively relieve inflammation if damage seems largely superficial.

Use Oral Immunosuppressants Temporarily

Short course steroids or medications like cyclosporine could “reset” the immune axis without adrenal impairment long-term.

Think Beyond Steroids

Evolve treatment plans to use non-steroid options like pimecrolimus or Eucrisa to avoid addiction risk when controlling future flares.

With insights from thought leaders complementing ongoing research, the approach to TSW will only continue to be refined and improve.

Patient Advocacy Perspectives

The Red Skin Syndrome nonprofit organization offers extensive education, guidance and emotional support for TSW patients. Founder Kathryn Mangipane highlights that:

“This painful condition frequently goes unrecognized for years. Raising awareness and validating patient experiences are as crucial as pursuing new treatments.”

This aligns with what the National Eczema Society outlines regarding TSW:

“Further research into this devastating condition is vital. But we must also prioritize equipping patients, families and healthcare professionals with the information needed to avoid TSW’s crippling long-term effects.”

A dual approach of expanding medical knowledge and public access to that knowledge will produce the greatest strides helping those battling topical steroid withdrawal.

Frequently Asked Questions

What’s the difference between topical steroid withdrawal and a generic eczema flare?

While TSW mimics exacerbated eczema, key differences include onset after stopping steroids (not random), localization to areas of prior steroid use, and presence for months without resolution (rather than transient flaring).

Can moisturizers and emollients adequately treat TSW?

Moisturization and barrier repair products can soothe associated dryness and sensitivity. But they don’t address the underlying pathophysiology driving inflammation so cannot independently resolve TSW.

Is premature aging of skin a side effect of topical steroid withdrawal?

Yes, long term TSW appears to impair collagen production and encourages breakdown leading to wrinkling, easy brusing, and slow healing. Mitigating severity of withdrawal through early management limits these effects.

Can TSW arise from using OTC 1% hydrocortisone cream available without prescription?

Potentially yes – while lower potency, exceeding reccomended administration duration of 1-2 weeks when using hydrocortisone still risks HPA axis suppression making TSW possible. Monitoring usage is key.

Does topical steroid withdrawal syndrome only occur in people with underlying atopic dermatitis?

No – while those with atopic dermatitis use more topical steroids raising risk, TSW represents a seperate phenomenon that can develop independently of whether a background skin condition is present.

Conclusion and Key Takeaways

Topical steroid withdrawal remains an evolving concept in dermatology and much still needs elucidating regarding contributory mechanisms. But through reviewing foundational evidence and guidance from leading experts, we can highlight several key points for awareness and management:

What We Know

  • TSW likely stems from two concurrent processes of HPA axis dysfunction and skin barrier impairment
  • Risk rises with higher steroid potency, longer duration of use, damaged skin integrity, and abrupt discontinuation
  • Careful withdrawal of steroids allows avoiding adrenal insufficiency
  • Supportive wound care and immunomodulators can alleviate symptoms
  • Patient education and advocacy empower those struggling with TSW

What We’re Still Learning

  • Ideal protocols for tapered withdrawal and transitioning to non-steroidal treatments
  • Role of newer therapies like JAK inhibitors and emerging biologics
  • Logistics of access and coverage for treatment options
  • Long term prognosis with adequate intervention across patient groups

TSW remains highly variable in presentation and course. But centering individualized care plans and self-management skills equips patients to have the best outcomes possible while research continues evolving best practices for the medical field at large.

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