What Is Topical Steroid Withdrawal?

Topical steroid withdrawal (TSW), or "red skin syndrome," can occur when you stop using topical corticosteroids after prolonged use. Corticosteroids are anti-inflammatory medications commonly prescribed to treat various skin conditions, such as eczema, psoriasis, and other inflammatory skin disorders. While topical corticosteroids can effectively manage inflammation, they are meant for short-term use to avoid dependence and withdrawal.

TSW can cause severe skin-related symptoms such as redness, flaking, peeling, swelling, and intensely itchy or burning skin that spreads to different areas of the body. Sometimes TSW can trigger a "rebound" effect, causing worsened symptoms of the initial skin condition treated with topical corticosteroids.

Topical steroid withdrawal can be distressing; many people going through TSW experience insomnia, anxiety, and depression. Fortunately, there are ways to help ease the symptoms until TSW subsides. 

What Causes Topical Steroid Withdrawal?

Topical steroid withdrawal (TSW) can occur when you use topical corticosteroids on your skin for a prolonged period. The specific cause of TSW is not fully understood, but it is thought to be related to the body's adaptation and dependency on the medication over time. 

When used for an extended period, topical corticosteroids can lead to a phenomenon known as "tachyphylaxis." Tachyphylaxis is a reduced response to medication after continued use. Long-term use of topical corticosteroids can cause the skin to become less responsive to the medication's effects over time, requiring higher and higher doses to achieve the same level of relief.

Using corticosteroids for an extended period—or more often than prescribed—may cause your skin to depend on the medication to maintain normal function. Abruptly stopping or tapering off topical corticosteroids can lead to a rebound effect, where your skin experiences a flare-up of inflammation and other withdrawal symptoms.

Statistics

Current and comprehensive statistics on how many people are affected by TSW are unknown, likely due to underreporting and limited research on the condition. A 2015 study reported that TSW is most common when corticosteroids are applied to the face and genital area, and is most common in women who used potent topical corticosteroids long-term, sometimes more often than prescribed.

Awareness and understanding of topical steroid withdrawal are increasing among healthcare professionals, which will lead to more research and understanding of how many people have experienced TSW.

Symptoms of Topical Steroid Withdrawal

Topical steroid withdrawal symptoms can vary in severity and from person to person. Common TSW symptoms include:

• "Red burning" or "redraw" appearance of the skin
• Intense and persistent itching (pruritus)
• Burning or stinging sensations on the skin
• A "red sleeve" of inflamed skin on the arms or legs
• Dry and flaky skin
• Swelling (edema)
• Oozing and crusting of the affected areas
• Skin hypersensitivity and pain
• Increased sensitivity to touch and temperature changes
• Sleep disturbances due to itching and discomfort
• Emotional distress and anxiety related to the symptoms
  

How long topical steroid withdrawal lasts can vary. In some cases, TSW may resolve within a few weeks; in others, it can last for several months or years. Factors influencing the duration of withdrawal include:

• The potency of the topical corticosteroid used
• The duration of usage
• The frequency of application
• Individual differences in skin sensitivity 

When to Contact a Healthcare Provider

Talk to a healthcare provider if you suspect you are experiencing topical steroid withdrawal or have the following symptoms:

• Persistent and worsening symptoms such as severe redness, intense itching, burning sensations, or skin changes after prolonged use of topical corticosteroids
• Skin thinning or increased skin irritation, or unexpected reactions
• Worsening symptoms of your skin condition (e.g., eczema) while using topical corticosteroids 
• Sudden changes in skin appearance, such as skin discoloration, rashes, or blisters
• Emotional distress and sleep problems 
  

Talk to your healthcare provider if you are currently using topical corticosteroids and are concerned about your medication. Your provider may recommend gradually reducing topical corticosteroid use to prevent withdrawal and manage your skin condition effectively. 

How to Find a TSW Healthcare Provider

Finding a healthcare provider aware of and educated in managing TSW can be challenging due to the relatively recent recognition of the condition and its evolving understanding within the medical community. Many healthcare professionals may have yet to encounter TSW during their training or clinical practice, leading to misdiagnosis or underdiagnosis.

Don't lose hope if your current healthcare provider is unfamiliar with the condition. To find the right healthcare provider, consider:

• Contacting a dermatologist: Dermatologists are specialists in treating skin conditions and may better understand TSW. Seeking a dermatologist with experience managing TSW can increase your chances of receiving an accurate diagnosis and appropriate management.
• Looking for support online: Online support groups and forums for people dealing with TSW can be valuable resources. Others may share their experiences and recommend healthcare providers who are knowledgeable about the condition.
• Getting referrals: Reach out to local or national patient advocacy groups related to skin conditions (e.g., National Eczema Association). These organizations might have a network of healthcare providers familiar with TSW and can provide referrals.
• Seeking telehealth options: If you don't have local access to healthcare providers experienced in TSW, exploring telehealth options can open up possibilities for connecting with specialists or experts in TSW who may be located in different regions.
  

How Is Topical Steroid Withdrawal Treated?

There are no treatment guidelines for TSW, so treatment focuses on managing symptoms. Since TSW can vary in severity and duration from person to person, treatment plans are often personalized based on individual needs. Common approaches to treating TSW include:

• Gradual tapering of corticosteroids: Healthcare providers may recommend tapered oral corticosteroid use to help the skin gradually adjust to the medication's reduced presence and minimize the risk of rebound flares.
• Moisturization: Keeping the skin well-hydrated is crucial during TSW. Moisturizers can help soothe and hydrate dry and irritated skin, reducing itching and discomfort. 
• Monoclonal antibodies: Rinvoq (upadacitinib), a biologic medication used to treat inflammatory skin conditions, has shown promise in helping treat TSW. This is an oral medication that may help reduce symptoms such as redness, itching, and inflammation.
• Symptomatic relief: Medications to manage symptoms, such as antihistamines, may be prescribed to relieve itching and help you sleep better. 
• Stress management: Stress can exacerbate TSW symptoms, so implementing stress-reducing techniques, such as mindfulness practices, relaxation exercises, or counseling, may be beneficial.
• Supportive care: Support groups and counseling can provide emotional support and practical advice for coping with the challenges of TSW.
• Regular monitoring: Regular follow-up appointments with a healthcare provider ensure your skin is being properly monitored and treatment adjustments can be made as needed.  
• Non-steroidal topical treatments: Medications such as Opzelura (ruxolitinib), Protopic (tacrolimus), and Eucrisa (crisaborole) may also help reduce symptoms.
  

Applying cold compresses to the affected areas or taking oatmeal baths to soothe irritated skin may be helpful.

Prevention

Preventing topical steroid withdrawal involves careful and responsible use of topical corticosteroids. While it may not always be possible to prevent TSW, certain measures may help lower the likelihood you experience it:

• Follow prescribed guidelines: Only use topical corticosteroids as directed by a qualified healthcare professional, typically a dermatologist. Follow the prescribed dosage, frequency, and duration of application.
• Short-term use: Limit the use of potent topical corticosteroids to short periods whenever possible. Avoid long-term use or continuous application without breaks.
• Avoid strong steroids on sensitive areas: Avoid using potent corticosteroids on sensitive areas of the skin, such as the face, underarms, groin, and areas with thinner skin. 
• Use the lowest potency: Start with the lowest-strength corticosteroid that effectively manages your skin condition. More potent steroids should be reserved for severe flare-ups and used only for short durations.
• Gradual tapering: If you have used topical corticosteroids for an extended period, talk to your healthcare provider about a gradual tapering plan to discontinue the medication. Abruptly stopping the use of topical corticosteroids can trigger withdrawal symptoms.
  

A Quick Review

Topical steroid withdrawal (TSW) can occur when you stop using topical corticosteroids after long-term use or use the medication more often than prescribed. Symptoms can be severe and distressing, including redness, intense itching, burning sensations, and peeling or flaky skin.

There is no standard treatment for TSW, so treatments focus on managing symptoms to reduce the impact of TSW on your quality of life. Following prescribed guidelines and avoiding long-term use may help prevent TSW.

If you suspect you have TSW, talk to a healthcare provider, such as a dermatologist, for a diagnosis, treatment recommendations, and supportive care.