Understanding Topical Steroid Withdrawal

June 29, 2024

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Topical steroid withdrawal (TSW), also known as steroid withdrawal or corticosteroid withdrawal, is a rare but serious condition that can occur when topical corticosteroids used to treat skin conditions like eczema are discontinued after prolonged, frequent, or inappropriate use[1]. It is characterized by severe steroid withdrawal symptoms affecting the skin, often worse than the original condition being treated.

Topical corticosteroids are medicated creams, ointments, or lotions applied directly to the skin to reduce inflammation and irritation. They are commonly prescribed to manage eczema (atopic dermatitis), psoriasis, and other inflammatory skin conditions[2]. While effective when used as directed, overuse or abrupt discontinuation of potent topical steroids can lead to topical steroid rebound effect and withdrawal.

TSW was first described in 1979 in patients who developed severe skin reactions after stopping topical steroid treatment. It has since been reported in both adults and children worldwide, though the exact prevalence is unknown. Recognizing the signs and risk factors of TSW is important for preventing and managing this distressing condition.

Symptoms of Topical Steroid Withdrawal

The hallmark of TSW is a severe rebound of skin inflammation and irritation within days to weeks of discontinuing the topical steroid. Symptoms are often more severe and widespread than the original skin condition. They can persist for weeks to months, and in some cases, full recovery may take years[1].

Common topical steroid withdrawal symptoms affecting the skin include:

  • Red, burning, stinging skin
  • Intense itching
  • Dry, flaky skin and skin peeling
  • Swollen skin, especially on the face and genitals
  • Skin sensitivity and pain
  • Pustules (pus-filled bumps)
  • Skin oozing and crusting

Other symptoms that may accompany TSW include:

  • Insomnia and fatigue
  • Anxiety and depression
  • Fever and chills
  • Lymph node swelling

The severity and duration of symptoms vary from person to person. Typically, the longer and more potent the topical steroid used, the more severe the withdrawal.

Causes and Risk Factors

TSW is thought to result from prolonged, frequent, or inappropriate use of topical corticosteroids leading to steroid dependence[1]. Normally, topical steroids are absorbed into the skin where they reduce inflammation. With chronic use, the skin becomes “addicted” to the steroid and unable to function normally without it.

Factors that increase the risk of developing TSW include:

  • Prolonged use of moderate to high potency topical steroids (longer than 2-4 weeks)
  • Frequent use (more than twice daily)
  • Use on sensitive areas like the face and genitals
  • Abruptly stopping topical steroids instead of gradually tapering
  • History of atopic dermatitis (eczema)
  • Being an adult, especially female

Inappropriate use of topical steroids, such as applying more often or longer than prescribed, also increases TSW risk. Using them to treat conditions they aren’t meant for, like fungal infections, can worsen the problem as well.

Diagnosing Topical Steroid Withdrawal

Diagnosing TSW can be challenging because the symptoms resemble severe eczema or psoriasis flares. There is no specific test for TSW. Diagnosis is based on a careful history and examination of the skin[1].

Key features that suggest TSW include:

  • History of prolonged topical steroid use, especially on the face or genitals
  • Red skin that is burning and stinging more than itching
  • Symptoms beginning within days to weeks of stopping the topical steroid
  • Rash spreading and becoming more severe over time
  • Failure to respond to usual eczema/psoriasis treatments

A skin biopsy can help rule out other conditions like psoriasis or fungal infections. Allergy testing (patch testing) may be done if allergic contact dermatitis to the topical steroid or other ingredients is suspected.

If you have been using topical steroids for a long time and develop worsening skin symptoms after stopping, it’s important to see a dermatologist. They can help determine if you have TSW and recommend an appropriate treatment plan.

Topical Steroid Withdrawal vs Eczema and Psoriasis

TSW can be mistaken for a severe eczema or psoriasis flare because the symptoms are similar. However, there are some key differences:

  • Eczema tends to be very itchy while TSW skin is more painful and burning[2]
  • Psoriasis plaques are usually thicker and scalier than seen in TSW[3]
  • Eczema and psoriasis usually respond to topical steroids while TSW will worsen with continued use
  • TSW often spreads rapidly, even to areas of the body where steroids were never applied

Your dermatologist can perform a thorough evaluation to differentiate between TSW and a severe eczema or psoriasis flare. This is important because the treatment approach is very different.

Treating Topical Steroid Withdrawal

There is no one-size-fits-all approach to treating TSW. The goal is to control symptoms while allowing the skin time to recover and regain its normal structure and function. Working closely with a dermatologist is the best way to manage TSW and prevent complications.

Steroid Tapering

In some cases, a gradual taper of the topical steroid may be recommended to minimize withdrawal symptoms[1]. This involves using a lower potency steroid or applying it less frequently over a period of weeks to months. Tapering should only be done under close medical supervision.

However, many dermatologists now favor quitting topical steroids cold turkey. A 2015 study in the British Journal of Dermatology found that patients who did a quick taper or stopped steroids abruptly had shorter withdrawal symptoms than those who tapered slowly[1].

Skin Care During TSW

Gentle skin care is essential during TSW to soothe irritation and promote healing. Some tips include:

  • Take lukewarm baths or showers and avoid hot water which can further dry and irritate skin
  • Use mild, fragrance-free cleansers and avoid harsh soaps or exfoliants
  • Apply a thick, fragrance-free moisturizer or emollient multiple times daily to combat dryness and itching
  • Try wet wrap therapy – applying moisturizer then covering skin with a damp cloth or clothing to boost hydration
  • Avoid triggers like sweat, heat, friction from clothing, and stress as much as possible

Keeping skin moisturized is important to improve the skin barrier and prevent infections. Look for products with ingredients like ceramides, hyaluronic acid, and petrolatum.

Medications for TSW

Oral steroids like prednisone are sometimes prescribed for a short course to quickly get inflammation under control during the early stages of TSW. However, this should be done cautiously as it can lead to severe rebound symptoms once the medication is stopped[1].

Steroid-sparing medications that suppress the immune system are occasionally used in more severe cases under expert guidance. Options include:

  • Methotrexate
  • Cyclosporine
  • Mycophenolate mofetil

Topical calcineurin inhibitors like tacrolimus and pimecrolimus are non-steroid medications that can help reduce inflammation and itch. They don’t cause skin thinning and are sometimes used instead of topical steroids if withdrawing from them[2].

Antibiotics may be prescribed if a secondary bacterial skin infection develops, which is common due to skin breakdown and cracking during TSW.

Antihistamines can help relieve itch and are useful to promote sleep at night. Topical anti-itch lotions containing menthol or pramoxine can provide additional relief.

Phototherapy

Narrowband UVB phototherapy involves exposing affected skin to controlled amounts of artificial ultraviolet light. It can help reduce inflammation and promote healing in TSW. Phototherapy is usually done 2-3 times weekly in a dermatologist’s office or at home with a prescription device[1].

Alternative and Complementary Therapies

Some people find alternative therapies helpful for managing TSW symptoms, though more research is needed on their effectiveness and safety. Options to discuss with your doctor include:

  • Acupuncture
  • Massage therapy
  • Biofeedback
  • Herbal remedies and supplements like fish oil, evening primrose oil, and vitamin D

Stress-relieving practices like meditation, deep breathing, yoga, and exercise can help manage the anxiety and depression that often accompany TSW.

Coping with TSW

TSW can be an intensely distressing and isolating experience. The physical discomfort combined with anxiety, depression, and lack of sleep can significantly impact quality of life. Seeking support is essential to help cope with TSW:

  • Let family and friends know what you are going through and how they can help
  • Connect with others going through TSW through online support groups like the National Eczema Association or TSW Atlas
  • Consider seeing a therapist or counselor to help manage the emotional challenges and develop coping strategies
  • Practice self-care activities you enjoy like reading, listening to music, crafting, or spending time in nature

Most importantly, be patient with yourself and the process. TSW is not a linear journey. There will be ups and downs, but with time and proper care, your skin will heal.

Preventing Topical Steroid Withdrawal

The best way to prevent TSW is to use topical steroids appropriately and only as directed by your doctor. Some general guidelines include:

  • Use the lowest potency steroid needed to control your symptoms
  • Apply a thin layer to affected areas only, not on healthy skin
  • Do not use for longer than 2-4 weeks continuously without a break
  • Do not apply more than twice daily
  • Avoid long-term use on sensitive areas like the face, genitals, and skin folds
  • Follow your doctor’s instructions for tapering or discontinuing use

If you have been using topical steroids for a long time, do not stop them suddenly without consulting your doctor. They can guide you on how to safely taper them to minimize withdrawal symptoms.

Be cautious with “natural” or “herbal” creams marketed for eczema or psoriasis as these may contain unlabeled steroids. Stick to products recommended by your dermatologist.

When to See a Doctor

See your dermatologist as soon as possible if you suspect you may be experiencing TSW. They can evaluate your skin, review your topical steroid use, and create an appropriate treatment plan.

Seek immediate medical care if you develop signs of infection like:

  • Sudden worsening of redness, swelling, and pain
  • Pus draining from the skin
  • Red streaks or rapidly spreading rash
  • Fever or chills

With proper treatment and support, it is possible to get through TSW and achieve healthy skin. Don’t hesitate to reach out for help.

Summary

  • Topical steroid withdrawal is a serious condition that can occur from prolonged, frequent, or inappropriate use of topical corticosteroids
  • Symptoms include severe burning, stinging, and red skin that appears after stopping topical steroids
  • Diagnosis is based on history of topical steroid use and examination of the skin
  • Treatment involves discontinuing topical steroids, gentle skin care, medications to control inflammation and itch, and phototherapy in some cases
  • Emotional support and coping strategies are essential when going through TSW
  • Topical steroids should only be used as directed by a doctor to prevent TSW
  • See a dermatologist if you suspect you have TSW or develop signs of skin infection

FAQs

How long does topical steroid withdrawal last?

The duration of TSW varies, but symptoms can persist for weeks to months after stopping the medication. In some cases, full recovery may take 1-2 years. Working with a dermatologist on a personalized treatment plan can help manage symptoms and promote healing.

Is it better to taper topical steroids or stop cold turkey?

The best approach depends on the individual situation and should be decided with a doctor’s guidance. In general, studies suggest that quitting abruptly or with a quick taper may lead to shorter overall withdrawal compared to a slow taper. However, some people may benefit from a gradual taper to minimize severe symptoms.

What is the difference between topical steroid withdrawal and eczema?

TSW is a specific adverse reaction to prolonged topical steroid use, while eczema is a chronic inflammatory skin condition. TSW skin tends to be more painful and burning compared to the intense itch of eczema. Eczema usually responds well to topical steroids, while they will worsen TSW.

Can diet changes help topical steroid withdrawal?

While there is no specific “TSW diet,” eating a balanced, nutritious diet is important to support skin health and overall well-being. Some people find reducing inflammatory foods like sugar and processed snacks to be helpful. Discuss any major dietary changes with your doctor.

How can I support a loved one going through topical steroid withdrawal?

Educate yourself on TSW so you can better understand what your loved one is experiencing. Offer practical help with daily tasks and encourage them to rest and practice self-care. Provide a listening ear and emotional support. If their mental health is suffering, encourage them to seek professional help.

References

  1. Sheary, B. (2018). Topical steroid addiction and withdrawal-An overview for GPs. Australian family physician, 47(10), 668-671. https://pubmed.ncbi.nlm.nih.gov/27622228/
  2. Fukaya, M., Sato, K., Sato, M., Kimata, H., Fujisawa, S., Dozono, H., … & Minaguchi, S. (2014). Topical steroid addiction in atopic dermatitis. Drug, healthcare and patient safety, 6, 131. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207549/
  3. Juhász, M. L., 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. https://journals.lww.com/jdnaonline/fulltext/2017/09000/systematic_review_of_the_topical_steroid_addiction.2.aspx
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