What is the recommended approach for tapering topical steroid dosage during withdrawal?

From the Guidelines

The recommended approach for tapering topical steroid dosage during withdrawal is to follow a tapering schedule with dose adaptation, as outlined in the European Dermatology Forum consensus, which suggests reducing the frequency of application over several months. This approach is based on the evidence from the British Journal of Dermatology study 1, which recommends a tapering schedule of daily treatment in the first month, treatment every 2 days in the second month, treatment twice per week in the third month, and treatment once per week starting in the fourth month.

Key Considerations

• The definition of disease control is crucial in determining when to start tapering, which is when new lesions or pruritic symptoms cease to form and established lesions begin to heal 1.
• Increasing the dose of topical steroids (up to 40 g per day) is recommended in patients who do not achieve disease control within 1-3 weeks 1.
• For maintenance, two options are available after 4 months of treatment, including stopping treatment or continuing with a lower dose 1.

Tapering Schedule

• Daily treatment in the first month
• Treatment every 2 days in the second month
• Treatment twice per week in the third month
• Treatment once per week starting in the fourth month

Additional Measures

• Increase moisturization with emollients like petroleum jelly or ceramide-containing moisturizers to manage dryness and irritation.
• Consider additional measures to control disease or for maintenance, such as adjusting the dose of clobetasol propionate 0.05% cream or ointment 1.

From the FDA Drug Label

If HPA axis suppression is noted, an attempt should be made to withdraw the drug, to reduce the frequency of application, or to substitute a less potent corticosteroid. Recovery of HPA axis function is generally prompt upon discontinuation of topical corticosteroids. Infrequently, signs and symptoms of glucocorticosteroid insufficiency may occur requiring supplemental systemic corticosteroids

The recommended approach for tapering topical steroid dosage during withdrawal is to attempt to withdraw the drug, reduce the frequency of application, or substitute a less potent corticosteroid if HPA axis suppression is noted.

• Withdrawal of the drug may be necessary to prevent further HPA axis suppression.
• Reducing the frequency of application can help minimize the risk of HPA axis suppression.
• Substituting a less potent corticosteroid can also help reduce the risk of HPA axis suppression. It is also important to monitor for signs and symptoms of glucocorticosteroid insufficiency, which may require supplemental systemic corticosteroids 2.

From the Research

Topical Steroid Withdrawal Approach

The recommended approach for tapering topical steroid dosage during withdrawal is crucial to minimize potential complications.

• A safe and practical algorithmic approach to steroid withdrawal can be determined in the physician's office 3.
• Improving patient awareness of the signs and symptoms of steroid withdrawal, close follow-up, and correct performance of the cosyntropin challenge are keys to success in withdrawing patients from steroid therapy 3.
• Intermittent ACTH and low-dose systemic cyclosporin administration can be used to treat patients with difficulties in steroid withdrawal, as seen in a case of a senile erythroderma patient 4.

Prevention and Management

• Being aware of topical corticosteroid (TCS) addiction and withdrawal can help practitioners prevent this adverse effect and offer supportive care to patients in TCS withdrawal 5.
• Patients and providers should be aware of the clinical presentation and risk factors of TCS withdrawal, which can be divided into papulopustular and erythematoedematous subtypes 6.
• Symptoms of TCS withdrawal can be difficult initially, but patients can ultimately improve, as seen in a case series of 10 children who developed features typically reported in adults experiencing topical steroid withdrawal 7.

Key Considerations

• TCS withdrawal is likely a distinct clinical adverse effect of TCS misuse, particularly with long-term inappropriate use of moderate-to-potent TCS on the face or genital area 5, 6.
• Burning and stinging are the most frequently reported symptoms, with erythema being the most common sign of TCS withdrawal 6.
• More research is required into long-term topical corticosteroid use and its discontinuation, including topical steroid withdrawal, particularly in the pediatric population 7.