Topical steroid withdrawal

Topical steroid withdrawal, also known as red burning skin and steroid dermatitis, has been reported in long-term users of topical steroids after they stop the use. Symptoms include redness of the skin, a burning sensation, and itchiness. This may then be followed by skin peeling.
It generally requires the application of a topical steroid at least daily for more than a year. It appears to be a specific adverse effect of topical corticosteroid use. People with atopic dermatitis are most at risk.
Treatment involves discontinuing the use of topical steroids. These can either be stopped gradually or suddenly. Counselling and cold compresses may also help. The condition is rare. Cases have been reported in adults with a few possible cases in children. It was first described in 1979.
Signs and symptoms.
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, itching, hot skin, swelling, and/or oozing for a length of time. This is also called 'red skin syndrome' or 'topical steroid withdrawal' (TSW). 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.
Duration.
The duration of acute topical corticosteroid withdrawal is variable, it can take months to years to return to the skin's 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.
Cause.
It generally requires the application of a topical steroid at least daily for more than a year. It does not occur with normal use. Cases have, however, been reported to occur after as short as 2 months of use.
Mechanism of action.
Historically, it was believed that cortisol was only produced by the adrenal glands. Recent research has shown that keratinocytes in human skin also produce cortisol. Prolonged TS application changes the glucocorticoid receptor (GR) expression pattern on the surface of lymphocytes; patients experiencing resistance to TSs have a low ratio of GR-α to GR-β. In addition, the erythema characteristic of ‘‘red skin syndrome’’ is due to a release of stored endothelial nitric oxide (NO) and subsequent vasodilation of dermal vessels.
Diagnosis.
Diagnosis is based on a rash occurring within weeks of stopping long term topical steroids. Headlight sign - redness of the lower part of the face but not the nose and around the mouth. Red sleeve - rebound eruption stopping suddenly at lower arms and hand. Elephant wrinkles - reduced skin elasticity. Differentiating from the skin condition the steroids were used to treat can be difficult. Red burning skin may be misdiagnosed.
Prevention.
Prevention is by not using moderate or high strength steroid creams for periods of time longer than two weeks.
Treatment.
Treatment involves safely decreasing topical steroids.they should not be stopped without consultation of the doctor to prevent worsening of the symptoms These can either be stopped gradually or suddenly. Counselling and cold compresses may also help. Antihistamines may help for itchiness. Immunosuppressants and light therapy may also help some people. Psychological support is often recommended. At this time treatment options that have been documented in literature include Tacrolimus, Pimecrolimus, and Dupixent. Some physicians have also seen positive outcomes with oral Doxycycline and/or topical Clindamycin.
Epidemiology.
The condition is rare. Cases have been reported in adults with a few possible cases in children. One survey estimated that maybe up to 12% of people with atopic dermatitis have steroid addiction.
History.
The first description of the condition occurred in 1979.