What Is Topical Steroid Withdrawal? Everything to Know

Topical corticosteroids are commonly prescribed to treat a variety of skin conditions like eczema, psoriasis, and dermatitis by reducing inflammation and irritation. While they are effective in managing these disorders, long-term use or improper application can lead to a condition known as topical steroid withdrawal (TSW). This article delves into the uses of topical steroids, the potential risks of withdrawal, and how to manage and prevent TSW.

What Is Topical Steroid Withdrawal?

Topical steroid withdrawal (TSW) is an emerging clinical problem that is not fully understood at present. People with TSW develop redness and burning following discontinuation of mid- to high-potency topical corticosteroids after long-term topical corticosteroid use.

A TSW skin condition is frequently interpreted as a flare-up of the underlying skin disorder for which topical corticosteroids were prescribed or as a contact allergy to topical steroid treatment.

Some patients have reported dismissal of their symptoms by their skin-care specialist. The differences in opinion between dermatologists and patients experiencing topical steroid withdrawal can lead to challenges in treating the condition and a breakdown of the patient-dermatologist relationship.

Topical steroid withdrawal (TSW) is also called:

Red Skin Syndrome
Red Burning Skin Syndrome
Steroid withdrawal syndrome
Steroid cream withdrawal
Steroid dermatitis

Because of a lack of research and the absence of clear diagnostic criteria, we don’t know how many people have TSW, what percentage of people using topical steroids develop it, or what amount of steroid use causes it.

We do know that concerns about TSW or red skin syndrome can lead to topical steroid (TCS) phobia, which is a fear of topical corticosteroids.

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What Are Topical Steroids?

Topical steroids are corticosteroid medicines applied directly to the skin to treat skin conditions that cause pain, irritation, and inflammation. Conditions that may require topical steroid use include chronic atopic dermatitis (eczema), allergic contact dermatitis, and psoriasis. Topical steroids do not cure the underlying disease but help control skin symptoms.

They are available in various forms, such as creams, ointments, lotions, gels, solutions, and bandages. Topical corticosteroids are categorized into four potencies (strengths): low, mid, high, and ultra-high.

Note: Steroid hormones are made by the adrenal glands and play many vital roles in the body. Oral corticosteroids (glucocorticoids) are prescription medications that are used for various medical purposes. They work by attaching to the glucocorticoid receptor and suppressing immune system activity. Topical corticosteroids cause fewer side effects than the oral forms because they are applied directly to the skin.

Learn more about the difference between corticosteroids and glucocorticoids.

What Are Examples of Topical Steroids?

Low-potency topical corticosteroids include:

Medium-potency topical corticosteroids include:

Potent topical corticosteroids include:

Low-potency steroids are sometimes available over-the-counter but usually require a prescription. Medium potency steroids and higher are only available with a doctor’s prescription.

What Triggers TSW?

Patients with atopic dermatitis and other chronic inflammatory skin disorders are often prescribed topical corticosteroids as first-line treatments to manage the condition. While these drugs are effective in controlling dermatoses symptoms, improper use can lead to side effects and long-term complications.

Stopping Regular Use

TSW is mainly caused by stopping the regular use of corticosteroids, but the details of who can be affected are unclear. Stopping topical corticosteroids after prolonged use increases nitric oxide levels, which causes vasodilation (widening) of blood vessels in the skin. The terms Red Skin Syndrome or Red Burning Skin Syndrome are used because TSW can cause whole body flushing or redness with painful burning sensations. Notably, red refers to inflammation (note that the skin may not always appear red, depending on the skin tone).

Experts use the term topical steroid withdrawal because they believe the body develops a tolerance to topical steroids. Since the body naturally produces corticosteroids, it decreases the amount it produces to compensate for topical steroid usage. Therefore, when a topical steroid is stopped, there is a rebound effect because the body is no longer making enough corticosteroids for its needs. New symptoms emerge, or previous symptoms re-emerge that are more severe compared to pretreatment levels.

Other Risk Factors For Developing TSW

Studies suggest that TSW is more common in adult women with moderate- or high-potency topical steroid use in sensitive areas such as the face or genital region. Risk factors for TSW include:

Use of topical corticosteroids in sensitive areas such as the face or genitals by adult patients.
Prolonged topical steroid use daily.
Use of topical steroids without periodic breaks or a tapering dose.

Symptoms of Topical Steroid Withdrawal

Skin-Related Symptoms

Burning pain
Erythema (body redness)
Flaking, peeling, shedding of skin
Swelling
Thinning or wrinkling of the skin
Skin atrophy or elephant wrinkles
Cracking of the skin
Nodules, papules, or papulopustular lesions on the skin
Pus-filled bumps and oozing
Hair loss

Non-Skin Related Symptoms

Insomnia
Feeling hot or cold
Fatigue
Nerve pain (sometimes called sparklers or zingers)
Enlarged lymph nodes
Eye dryness
Changes in appetite
Anxiety and depression due to severe symptoms

TSW vs Eczema Flare-Ups

It can be difficult to differentiate between topical steroid withdrawal symptoms and worsening of the underlying condition. Warning signs that point to TSW versus an eczema flare include:

Spread of skin symptoms to new areas that were previously unaffected or untreated.
Change in symptoms, for example, from itching to stinging or burning.
Change in the appearance of the affected area, for example, from a rash to a flushed or sunburned appearance.
General erythematoedematous reactions (redness and swelling in a sleeve-like pattern) on the arms or legs versus a patchy appearance in eczema flares.

How Do Symptoms Progress?

According to the National Eczema Association, patients report that topical steroid withdrawal symptoms can be intermittent and may get progressively worse over time. Some people become homebound, unable to hold down a job or attend social events. However, this level of severity is rare.

People who have lived with TSW for years say it can be emotionally exhausting and affect every facet of life, with physical, emotional, social, and economic ramifications.

Moreover, because TSW is underrecognized among many dermatologists and the eczema community, the condition can be isolating, leading to severe anxiety, depression, and even suicidal thoughts.

Does TSW Ever Go Away?

TSW can go away with treatment. Many people report complete, long-term relief and normal skin once the withdrawal symptoms resolve. However, topical steroid withdrawal symptoms can last for weeks, months, or even years. Because this skin disorder is so rare, there is no average time estimate for recovery. Anecdotal reports suggest that recovery from TSW often takes at least three months, but many people report struggling with it for years.

What Can Worsen or Improve Symptoms?

Restarting the use of mid- or high-potency steroids daily after TSW develops can worsen TSW symptoms. Gradually stopping topical steroids can improve symptoms.

How To Prevent Topical Steroid Withdrawal

While topical steroid use can be very effective in managing inflammatory skin conditions, patients with atopic dermatitis and other chronic skin disorders are at a higher risk of developing TSW with daily prolonged use of topical steroids. Instead, intermittent use of topical steroids, for example, twice a week, is recommended.

Proper topical corticosteroid use is the only way to prevent TSW (withdrawal reactions after stopping topical corticosteroids). It’s important to follow your dermatologist’s treatment plan and use the lowest strength and minimum amount of topical steroids (steroid creams, ointments, gels, lotions, and solutions applied directly to the skin). Generally speaking, topical corticosteroids should be reserved for flare-ups, and non-steroidal anti-inflammatory treatments should be used for longer-term management.

Note: Some people can develop steroid phobia after a family member develops TSW or after they read about the condition. A fear of steroids can prevent them from using topical steroids to treat an inflammatory skin disorder. However, it’s important to understand that TSW is a rare condition, and the risk of developing it is very low with proper use and topical steroid safety.

Non-Steroid Treatment Options

Another way to prevent topical steroid withdrawal is to use non-steroid dermatological treatment, for example:

Zinc oxide and zinc pyrithione for seborrheic dermatitis.
Vitamin D analogs such as calcipotriol, calcitriol, tacalcitol, and maxacalcitol.
Topical calcineurin inhibitors such as tacrolimus and pimecrolimus.
Newer biologics and JAK inhibitors.

People needing long-term management of skin conditions should also discuss non-pharmacological treatments with their dermatologist, including:

Avoidance of known triggers.
Moisturizers and skin barrier repair products.
Wet wrap therapy.
Skin bleaching.
Special soothing fabrics.
Mind-body approaches and psychological interventions.

How To Prevent Recurrence of Topical Corticosteroid Withdrawal

Research suggests that practicing topical steroid safety is the best way to prevent topical corticosteroid withdrawal. Prevention includes using the lowest strength and amount of topical steroid medication necessary to control your symptoms, taking periodic treatment breaks, and using non-steroid treatments to manage the condition. The goal should be to avoid long-term daily use of moderate- to high-potency steroids, which is the leading risk factor for TSW.

If your skin disorder recurs shortly after stopping treatment with topical corticosteroids (within 2 weeks), do not restart using the steroid creams without consulting your dermatologist unless your doctor has previously told you to do so.

If your skin condition resolves but recurs, the redness extends beyond the initial treatment area, and/or you develop a burning sensation, call your dermatologist before restarting topical corticosteroids.

Diagnostic Procedures

There are no accepted diagnostic criteria for topical steroid withdrawal as yet. Dermatologists who treat TSW look for the following to make a diagnosis of TSW versus severe eczema:

A history of prolonged use, especially escalating use, of medium or high-potency topical steroids.
Complaints of skin burning as opposed to the intense itching caused by eczema.
Confluent redness in a sleeve-like pattern versus patches of eczematous skin.

It’s important to consult a dermatologist so they can rule out the differential diagnosis (other conditions that can cause similar symptoms). Arriving at an accurate diagnosis is the first step towards effective management of TSW.

Treatments for Topical Corticosteroid Withdrawal or Steroid Addiction

TSW is caused by the improper and sometimes proper use of topical steroids. The primary treatment can include restarting the steroid with a taper or restarting at a low-potency steroid.

There is no proven treatment that can cure TSW or speed up recovery. A systematic review of studies does not reveal an evidence-based treatment plan that works for all or most patients.

Therefore, TSW is managed on a case-by-case basis. It consists of supportive care, including symptom control, physical and emotional comfort measures, infection prevention, sleep aids, therapies for anxiety and depression, and other medical interventions, as needed.

The treatment plan may consist of one or more of the following:

A slow taper of topical steroid use under medical supervision. Abrupt discontinuation after a prolonged course of topical steroids can result in an adrenal crisis due to adrenal suppression or HPA axis suppression (this occurs because the adrenal glands stop making steroid hormones after long-term treatment with exogenous corticosteroids).
Antihistamines to control itching.
Pain relievers to reduce discomfort.
Oral corticosteroids: A short course of oral steroids can help with TSW. Doctors gradually reduce the strength of the oral corticosteroids throughout TSW treatment.
Antibiotics to prevent or treat secondary skin infections.
Immunosuppressants such as cyclosporine.
Dupilumab (Dupixent) is a prescription medication administered by subcutaneous injection for severe and refractory atopic dermatitis. It has shown some benefit in people with topical corticosteroid withdrawal.
Ice packs or cold compresses for relief from pain, redness, and discomfort.
Skin moisturizers to promote healing.
Light therapy to improve redness and other symptoms.
Psychological support for anxiety and depression related to TSW.

Finding Support For Topical Corticosteroid Withdrawal

TSW is currently an under-recognized condition. However, people with TSW disease can develop severe symptoms, to the point of causing them to be homebound and severely depressed, even suicidal.

If you or a loved one is experiencing topical steroid withdrawal syndrome, it’s important to find a supportive doctor and consult them before stopping topical steroids. A doctor can help you safely discontinue topical corticosteroids while offering comfort measures to manage withdrawal symptoms. You can also find support and further information about TSW from the International Topical Steroid Awareness Network (ITSAN).