From the Guidelines
Topical steroid withdrawal (TSW) is a condition that occurs when someone stops using topical corticosteroid medications after prolonged use, resulting in a rebound effect with symptoms often worse than the original skin condition, as noted in the joint AAD-NPF guidelines of care for the management and treatment of psoriasis with topical therapy 1. This reaction typically happens after frequent, long-term application of moderate to high-potency topical steroids, especially on sensitive areas like the face or intertriginous areas, which are at greatest risk to develop adverse effects such as skin atrophy, striae, folliculitis, telangiectasia, and purpura 1. Some key points to consider about TSW include:
- Symptoms include intense redness, burning, stinging, peeling skin, oozing, swelling, and severe itching that can spread beyond the original treatment area
- These symptoms may last weeks to months as the skin heals
- TSW occurs because extended steroid use can suppress the skin's natural functions and cause dependence, leading to inflammation when the medication is discontinued
- To manage TSW, complete cessation of all topical steroids is usually necessary, though this should be done under medical supervision
- During recovery, gentle skincare with minimal products, cool compresses, and moisture management can help ease symptoms
- Prevention involves using the lowest effective potency of topical steroids for the shortest duration possible, with scheduled breaks in treatment for chronic conditions requiring long-term management, to minimize the risk of rebound and other adverse effects 1.
From the Research
Definition and Characteristics of Topical Steroid Withdrawal
- Topical steroid withdrawal (TSW) is a skin condition characterized by red burning, itchy, painful skin lesions, often accompanied by peeling, and cracking 2.
- It is described as a rebound effect following discontinuation of prolonged use of mid-to-high-potency topical corticosteroids 2, 3, 4.
- Symptoms of TSW include erythema, itchiness, burning, and secondary lesions such as scales 3, 4, 5.
- TSW can be divided into papulopustular and erythematoedematous subtypes, with the latter presenting with more burning and edema 5.
Clinical Presentation and Diagnosis
- TSW is frequently interpreted as flaring of the underlying disorder or contact allergy to topical treatment 2, 3.
- There is no consensus diagnostic criterion for TSW, making it often misdiagnosed 2, 3, 6.
- Patients with TSW may experience sleep disturbances due to intense itching, significantly impacting their quality of life 2.
- A majority of affected individuals develop secondary bacterial infection, marked by heavy colonization of Staphylococcus aureus (S. aureus) and alterations in the skin microbiome 2.
Management and Treatment
- Recognizing and effectively managing TSW is critical for healthcare providers seeking to develop comprehensive management plans 2.
- Management plans typically include supportive therapy for both physical and psychological symptoms, as well as the gradual tapering of corticosteroid use before complete discontinuation 2.
- Patient education and follow-up are important to address improper usage of topical corticosteroids 4.
- Open psychodermatology consultations with an earlier introduction of conventional management options can lead to improvements in TSW symptoms 3.