What is Topical Steroid Withdrawal (TSW)?

Topical steroid withdrawal (TSW) (also sometimes called ‘red skin syndrome’ (RSS) and ‘topical steroid addiction’) is a clinical adverse effect that can occur from the overuse or inappropriate use of topical corticosteroids. 

The most commonly reported reactions include intense itching and burning, irritation, cycles of flaking skin, skin exfoliation, oozing and bright red skin. These symptoms are the typical features of topical steroid overuse and withdrawal. They are thought to occur with prolonged use of moderate to high potency topical corticosteroids. The signs and symptoms occur within days to weeks after stopping topical steroid treatment.

Although generally safe and effective, topical steroids can also rarely lead to serious side effects, such as thinning of the skin, adrenal suppression, or in very rare cases, Cushing’s Syndrome, due to systemic absorption. The likelihood of these severe effects depends on the amount, potency, and duration of topical steroid use.

Who is likely to suffer from TSW?

According to research, TSW reactions are more commonly seen in adult women who apply moderate to high potency topical corticosteroids to the face or genital region. It is often associated with more prolonged and regular use of topical steroids without tapering or taking periodic breaks between treatment courses.

It is also important to highlight that topical steroids can be used safely and effectively for eczema and other inflammatory skin conditions. For many, the use of topical steroids result in major improvements in their quality of life.

Symptoms of TSW

Common symptoms of TSW include:

  • Redness and warmth of the skin
  • Intense itching and burning sensation
  • Shedding or peeling of the skin
  • Oozing of clear fluid or pus
  • Thickened, leathery skin (lichenification)
  • Pain and discomfort

Management and Treatment of TSW

Managing TSW involves several strategies:

  • Gradual Tapering: Slowly reducing the use of topical steroids rather than abrupt cessation.
  • Supportive Care: Using emollients and moisturisers to maintain skin hydration.
  • Medical Supervision: Regular follow-up with your GP or Dermatologist, to monitor the condition and adjust treatment as necessary.
  • Alternative Treatments: Exploring non-steroidal options for managing the underlying skin condition, such as calcineurin inhibitors (e.g., tacrolimus, pimecrolimus) and lifestyle modifications.

Prevention of TSW

  • Appropriate Use: Using topical steroids as prescribed by your GP or Dermatologist, adhering to the recommended duration and potency.
  • Education: Being informed about the potential risks of prolonged steroid use and recognizing early signs of TSW.
  • Regular Review: Periodically reviewing treatment plans with your GP or Dermatologist to ensure the continued appropriateness of the therapy.

Steroid use at Skin + Me

Our Hydroquinone-containing formulations contain Hydrocortisone at 0.5% strength (classified as mildly potent corticosteroid) and this is usually prescribed in short courses of at least 8 weeks duration. 

Strict measures are in place at Skin + Me to ensure that this formulation is prescribed with periodic breaks of at least three months to avoid the overuse of both Hydroquinone and Hydrocortisone. While the risk of TSW with lower potency corticosteroids is theoretically very low, it is important to be aware of this risk and follow the advice of your prescriber. Seek medical advice from your GP or Dermatologist before starting and if you start to experience any of these symptoms.

References:

  1. Topical Steroid Withdrawal Joint Statement: https://cdn.bad.org.uk/uploads/2024/02/22095550/Topical-Steroid-Withdrawal-Joint-Statement.pdf
  2. Topical Steroid Withdrawal reactions: A review of the evidence:https://www.gov.uk/government/publications/topical-steroid-withdrawal-reactions-a-review-of-the-evidence/topical-steroid-withdrawal-reactions-a-review-of-the-evidence

A systematic review of topical corticosteroid withdrawal (“steroid addiction”) in patients with atopic dermatitis and other dermatoses https://doi.org/10.1016/j.jaad.2014.11.024