In this 2 part series we are investigating topical steroids, as well as topical steroid withdrawal.
In our previous article, Part 1, we discussed what it is, how it works, in what forms it is available, what it is used for and how to use it. In this article, Part 2, we will discuss the dangers of overuse.
TSW – Topical Steroid Withdrawal
The term “topical steroid withdrawal” (also referred to as topical steroid addiction, steroid withdrawal syndrome or red skin syndrome) refers to a constellation of symptoms that may emerge in the days and weeks after a person stops the use of topical corticosteroids. Due to a lack of research and no clear diagnostic criteria, it’s not yet known what amount of steroid use causes TSW, how many people have the condition and what percentage of people using topical steroids may develop it.
However, according to a systematic review of topical corticosteroid withdrawal published in the Journal of the American Academy of Dermatology and initiated by National Eczema Association (NEA):
“TSW is more commonly seen in adult women who apply mid- or high potency topical corticosteroids to the face or genital region. The condition seems to be associated with more prolonged use of daily topical steroids, topical corticosteroids to more sensitive areas or use of topical steroids without tapering or periodic breaks.”
The first description of the condition occurred in 1979.
A systematic review (meta-analysis) in accordance with evidence-based medicine frameworks and current research standards for clinical decision-making was performed in 2016 and was republished with updates in 2020.
What is topical corticosteroid withdrawal?
Topical corticosteroid withdrawal refers to a rare adverse reaction relating to the use of a topical steroid after it has been discontinued. It can occur after prolonged, inappropriate, and/or frequent use/abuse of moderate- to high-potency topical corticosteroids. Most reports of side effects follow the prolonged use of an unnecessarily potent topical steroid for conditions not warranting such strong treatments.
There are two distinct clinical presentations of topical steroid withdrawal:
- Red burning skin – this has incorrectly been given a variety of names, including topical steroid addiction and steroid dermatitis.
- Papulopustular rashes – these include steroid rosacea and perioral/periorificial dermatitis.
How does TSW develop?
Topical steroid withdrawal, also known as red burning skin and steroid dermatitis, has been reported in people who apply topical steroids daily for 2 weeks or longer and then discontinue use. Symptoms affect the skin and include redness, a burning sensation, and itchiness, which may then be followed by peeling.
It appears to be a specific adverse effect of topical corticosteroid use. People with atopic dermatitis are most at risk.
First signs of over-use
Topical steroid addiction (TSA) is characterised by uncontrollable, spreading dermatitis and worsening skin inflammation, which requires a stronger topical steroid to get the same result as the first prescription. This cycle is known as steroid addiction syndrome. When topical steroid medication is stopped, the skin experiences redness, burning, a deep and uncontrollable itch, scabs, hot skin, swelling, hives and/or oozing for a length of time. After the withdrawal period is over, the atopic dermatitis can cease or is less severe than it was before. Topical steroid addiction has also been reported in the male scrotum area. Other symptoms include nerve pain, insomnia, excessive sweating, anxiety, severe depression, fatigue, eye problems, and frequent infections.
Signs include the following:
- Skin thinning (atrophy)
- Stretch marks (striae) in armpits or groin
- Easy bruising (senile/solar purpura) and tearing of the skin
- Enlarged blood vessels (telangiectasia)
- Localised increased hair thickness and length (hypertrichosis)
Although it may even be prescribed for these conditions, a topical steroid can cause, aggravate or mask skin infections such as impetigo, tinea, herpes simplex, malassezia folliculitis and molluscum contagiosum.
When used correctly, in appropriate doses and potency, for short periods of time, along with preventative treatment measures, topical steroids remains the first-line treatment for infected eczema.
When is it dangerous
Stinging frequently occurs when a topical steroid is first applied, due to underlying inflammation and broken skin. Contact allergy to the steroid molecule, preservative or vehicle is uncommon, but it may occur after the first application of the product or even after many years of regular or intermittent use.
To prevent tachyphylaxis, a topical steroid is often prescribed to be used on a week on, week off routine. Some recommend using the topical steroid for 3 consecutive days on, followed by 4 consecutive days off.
However, even with the break in use, long-term use of topical steroids can lead to secondary infection with fungus or bacteria (see tinea incognito), skin atrophy, telangiectasia (prominent blood vessels), skin bruising and fragility.
More serious side effects
Hypothalamic–pituitary–adrenal axis (HPA) suppression
Cushing’s syndrome
- Diabetes mellitus
- Osteoporosis
- Topical steroid addiction
- Allergic contact dermatitis (see steroid allergy)
- Steroid atrophy
- Steroid rosacea
- Pustular psoriasis.
- Perioral/Periorificial dermatitis dermatitis: This is a rash that occurs around the mouth and the eye region that has been associated with topical steroids, can occur in children
Ocular effects: Topical steroid drops are frequently used after eye surgery but can also raise intraocular pressure (IOP) and increase the risk of glaucoma, cataract, retinopathy as well as systemic adverse effects.
Tachyphylaxis: The acute development of tolerance to the action of a drug after repeated doses. Significant tachyphylaxis can occur by day 4 of therapy. Recovery usually occurs after 3 to 4 days’ rest. This has led to therapies such as 3 days on, 4 days off; or one week on therapy, and one week off therapy.
Other local adverse effects: These include facial hypertrichosis, folliculitis, miliaria, genital ulcers, and granuloma gluteale infantum. Long-term use has resulted in Norwegian scabies, Kaposi’s sarcoma, and other unusual dermatosis.
What are the clinical features of topical corticosteroid withdrawal?
- Before stopping the topical corticosteroid, the skin is typically normal or near-normal, although localised itch, ‘resistant’ patches of eczema or prurigo-like nodules may be present.
- Redness (erythema or flushing) typically starts on the face, genital area, or other steroid-treated site; in some cases this may extend to untreated sites.
- Early in the flare, the skin can feel quite thickened. Swelling (oedema) and papules can occur.
- The usual symptom described by patients is burning and/or stinging. Itch may also be reported, especially once the redness starts to fade and the dry scaly (desquamative) phase begins.
- Patients often report skin sensitivity, including intolerance to moisturisers and environmental factors. Excessive sweating and itchy weals are a sign of recovery.
One of the difficulties is determining whether the skin reaction observed is due to the stopping of topical corticosteroids, or is simply a worsening of the underlying skin disease for which the topical steroids had been prescribed.
Complications of topical corticosteroid withdrawal
Patients with red burning skin after topical corticosteroid withdrawal may be distressed by the intensity of itch, lack of sleep, and difficulty in treatment.
They may also develop secondary infection.
How is topical corticosteroid withdrawal diagnosed?
The definition of topical corticosteroid withdrawal requires the following features to be present:
- A rash that has appeared within days to weeks of discontinuing topical corticosteroid that has been used for many months. This flare may be worse than the pre-treatment rash.
- The rash must be only where the topical corticosteroid was being applied, at least initially, although it can later spread more widely.
- A flare of the underlying skin disorder such as atopic dermatitis can be difficult to distinguish clinically. Topical corticosteroid withdrawal should be considered if:
- Burning rather than itch is the main symptom
- The redness is confluent rather than patchy
- The rash resembles atopic dermatitis but involves unusual sites and is ‘different’
- There has been a history of continuous prolonged use of mid- or high-potency topical corticosteroid (greater than 1 year).
Skin biopsy is generally unhelpful to distinguish from a flare of the underlying skin disorder as the histopathology overlaps. Patch testing may identify some cases of contact allergy to the topical agents being applied to the skin, eg topical corticosteroid or other topical medications, moisturisers, cosmetics.
What is the treatment for topical corticosteroid withdrawal?
There is no agreed treatment for topical corticosteroid withdrawal, apart from ceasing the topical corticosteroid. However whether this should be tapered or abrupt has not been determined. Japanese reports suggest there is minimal difference in the outcome, so the recommendation is immediate cessation. A tapering course of oral steroids is helpful, as the addiction appears to relate only to the use of topical corticosteroids. Oral tetracyclines and low-dose isotretinoin have been used in steroid rosacea and perioral/periorificial dermatitis.
Supportive measures such as cold compresses and psychological support are often recommended. Prevention or treatment of secondary infection may require oral antibiotics. Our Eczema Skin Restoring Cream is a 100% natural cream designed to help the skin heal. It supports the skin’s own healing mechanisms to make it stronger.
Duration
The duration of acute topical corticosteroid withdrawal is variable; the skin can take months to years to return to its original condition. The duration of steroid use may influence the recovery factor time, with the patients who used steroids for the longest reporting the slowest recovery.
References
https://en.wikipedia.org/wiki/Topical_steroid
https://dermnetnz.org/topics/topical-steroid
https://www.webmd.com/drugs/2/drug-145116/cortisone-hydrocortisone-topical/details
https://www.nhs.uk/medicines/hydrocortisone-skin-cream/
https://www.rxlist.com/how_do_topical_corticosteroids_work/drug-class.htm
https://www.nhs.uk/conditions/topical-steroids/
https://nationaleczema.org/blog/tsw-need-to-know
https://dermnetnz.org/topics/topical-corticosteroid-withdrawal