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February 1, 2022
If you’ve been using topical steroids for any length of time, you may have heard about the possibility of withdrawal. While it’s not a common occurrence, it’s something that you should be aware of. In this article, we’ll discuss what topical steroid withdrawal is, how to recognize the symptoms, and what you can do to mitigate them.
Topical steroids are medications that are applied to the surface of the skin to reduce inflammation caused by conditions such as eczema, psoriasis, allergies, insect bites, and minor wounds.
Topical steroids are also called topical corticosteroids. They work by suppressing cells of your immune system that cause inflammation. Topical steroids are available in many different potencies, ranging from mild to super potent topical corticosteroids.
They are very effective at reducing symptoms of a variety of skin conditions. So much so that topical steroids tend to be the first line of treatment especially when you have eczema or psoriasis.
It is this very usefulness of the drug which has become a double-edged sword and made it vulnerable to now an alarming proportion with constantly rising instances of abuse and misuse leading to serious local, systemic, and psychological side effects.
Due to the nature of many skin conditions – where there are no known permanent treatment options, this results in the constant use of topical steroids in many patients.
Since topical corticosteroids control skin inflammation, not curing the condition, once topical corticosteroid medications are stopped, symptoms can return quickly and cause more severe reactions than before topical corticosteroids were started.
Topical steroid withdrawal (TSW) is a condition that follows the use of topical corticosteroids; it likely represents an attempt of the skin to counteract long-term glucocorticoid exposure. It’s also known as topical steroid addiction or red skin syndrome. A study done by the UK government has shown that a withdrawal reaction is relatively infrequent but it also suggests that numbers may be underreported.
Causes of topical steroid withdrawal include suddenly stopping topical corticosteroids or using topical corticosteroids improperly. For example, some people try to treat their skin condition from a mild topical corticosteroid to more potent topical corticosteroid medications than prescribed or for a long period of time when prescribed topical corticosteroids are no longer needed.
When a patient has been using TCSs for an extended period of time at high dosages, the lipid layer of the skin alters its composition.
Symptoms of topical steroid withdrawal
The severity of topical steroid withdrawal is believed to vary depending on the topical steroid that has been used, how long topical steroids were applied, and the strength of the topical steroids.
Topical steroid withdrawal causes erythema (redness), burning sensations or itching, and frequent infections. Secondary conditions associated with topical steroid withdrawal include seborrheic dermatitis, acne, miliaria (heat rash/prickly heat), secondary candidiasis, atopic dermatitis, steroid dermatitis, and psoriasis.
A systematic review in 2015 found that burning and stinging were the most reported symptoms with redness being the most common sign.
Topical steroid withdrawal, or red skin syndrome, can cause a range of other symptoms in addition to inflamed skin. These can include:
TSW is thought to be related to the body’s immune system and the hypothalamic-pituitary-adrenal (HPA) axis. HPA axis suppression can lead to decreased cytokine production and fewer inflammatory cells in the skin, which results in reduced clearance of bacteria and other microorganisms from the skin. As a result, some patients with acute topical corticosteroid withdrawal develop secondary infections such as impetigo, folliculitis, boils, cellulitis, and herpes simplex.
Patients experiencing TSW may be predisposed to psychiatric conditions during treatment because of changes in neurotransmitter function that occurs during HPA axis suppression.
There are some features that suggest a patient has TSW. The most important of these is the abrupt appearance or sudden worsening of redness, swelling, and itching without any other cause being found. However, this may not be present for several weeks after stopping treatment. In some cases, patients continue to use topical corticosteroids on and off for several months before symptoms appear.
The definitions of topical corticosteroids withdrawal have the following characteristics: An onset in a particular underlying condition of the skin is often difficult to differentiate clinically. Patch tests could detect contact allergies to topical agents such as corticosterone, other topically administered medicines, e.g. moisturizing products, cosmetics.
Patient experiencing red skin after withdrawal
Topical steroid withdrawal is very exhausting. It can affect anyone who has significantly used topical steroids to treat their skin conditions. It can undermine your mental health and worsen your underlying skin condition. Stories from across the world highlight that with proper awareness and therapy, there is hope against topical steroid withdrawal.
A woman in Canada, after using topical steroids for 14 years, experienced intense withdrawal symptoms. The pain became so bad that it eventually affected her mental health and she began thinking of self-harm.
This is very similar to a 29-year-old from Leeds, who at 21 was prescribed an immunosuppressant for her skin. She didn’t notice any improvement in her eczema after 4 months and decided to stop using it. She was then prescribed a number of potent topical corticosteroids over the years to counter flare-ups and yet her eczema deteriorated significantly leaving her in a cycle of depression that made her quit her job to focus on her skin and her mental health.
A case of topical steroid withdrawal was also reported in a toddler from Minnesota. The child suffered from mild eczema and was given topical steroids when he was 4 months old. The cream was used for over a year until upon realizing the dangers of overuse, the mother halted treatment. The withdrawal reaction in the child was weeping sores and scabs that erupted all over his body. He was left bedbound for weeks at a time and forced to sleep with socks taped to his hands so he wouldn’t scratch his eczema-prone skin.
This last case from Australia highlights the danger of 2 decades of topical steroid use – diagnosed with eczema as a child, topical steroids were the go-to solution for frequent flare-ups. Over the years he used moderate to high potency creams to deal with the symptoms. When he suddenly stopped usage – he was left with a burning or stinging sensation overnight. He was also experiencing skin thinning that left him with an increased chance of infections. A quick blood test confirmed that he was experiencing a blood infection due to his delicate skin that left him on a hospital drip for a month.
All of them healed after no longer using topical steroids. These cases illustrate how varied and dangerous topical steroid withdrawal is for any person at any age even in children. The unfortunate reality is that the NHS does not consider TSW as an official condition.
More awareness can lead to quicker response and better management can prevent a rise in people experiencing topical steroid withdrawal reactions.
Patients with TSW should be educated on the chronic nature of the condition, as there is no cure. It is important to avoid flares and intense treatment of the skin after tapering and discontinuing topical corticosteroids (TCSs), which commonly include topical calcineurin inhibitors (TCIs) and isotretinoin. The use of TCIs should be limited initially to moisturizing creams and healing emollients such as bland oatmeal preparations.
A tapering schedule is often used when discontinuing topical steroid medication to ensure the patient has several days without exposure to these medications. This can help reduce flares during withdrawal that may occur from abrupt withdrawal of the drug. Patients can also apply a moisturizing cream to the skin, such as hypoallergenic petroleum jelly, especially on the hands and face where flares of TSW are common.
A variety of topical and oral medications have been used to control symptoms during withdrawal. First-line treatments include TCIs or low-potency topical corticosteroids (e.g., desonide 0.05%) to control itch and inflammation; mid-potency topical corticosteroids (e.g., triamcinolone 0.1% cream) for more severe flares; and oral antihistamines, especially second-generation antihistamines such as loratadine and doxepin. A mild topical steroid reduces the chances of addiction compared to a high potency topical steroid.
Patients with TSW should also be educated on potential triggers to avoid, such as hot weather; sweating; new medications (including over-the-counter and herbal remedies); certain fabrics; viral infections; emotional stress; and ultraviolet or sun exposure. Patients should be evaluated for signs of infection by a physician if immunosuppression is severe.
Humidified air in the home or workplace, using fans to circulate air when possible, can help reduce symptoms of TSW by hydrating the skin and decreasing dryness. Bathing in lukewarm – not hot – water for 10 minutes at least twice daily also helps restore hydration to the skin. Drinking plenty of water daily is important for overall health, particularly when patients are experiencing flares or hydration is compromised due to fever or vomiting.
The better way for prevention is by alerting patients or doctors to the potential risk and avoiding frequent and long-term use. The higher the concentration and more frequent the application (more than once per day) the more prone it will be to topical corticosteroid withdrawals. It is important that people avoid topical corticotropins when they take topical corticosteroids because far more people respond to proper topical corticosteroid usage and develop an allergic reaction.
Medovie: skin care management without topical steroids
Don’t get us wrong – topical steroids are effective. But they are not a long-term solution. If you’re looking to ease your discomfort and improve the appearance of your skin, choose a more holistic approach with Medovie products.
Medovie is not just any other skincare brand. It is a restless company dedicated to its mission of helping people who are suffering from chronic skin conditions. It is built on a decade of extensive clinical studies that led to the ground-breaking development of the 3HX™ formula that is 96% natural and proven to have positive and recognizable results for chronic skin conditions.
We’ve combined the ancient wisdom of eastern medicine with the best scientific research of western medicine to create a product that has the best interests of people with chronic skin conditions
It is not addictive and does not carry the risks of topical steroids. Stopping use will not bring about any withdrawal reactions instead you’ll get the benefits of a natural skin care solution.
Medovie offers a range of scalp and body solutions that are clinically proven to work in addressing the appearance of your skin conditions/ Our products are all-natural and science-proven safe and effective in providing long-term holistic comfort for those battling restless eczema and atopic dermatitis skin problems.
In Medovie, we aim to help customers through every step of their skin healing journey with us.
Schedule a consultation with our scientific founder or a member of our team.
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