Topical steroid withdrawal “is a real and difficult-to-treat phenomenon that can occur while treating any chronic skin rash with topical steroids,” says Jeffrey S. Fromowitz, a dermatologist in Boca Raton, Fla. (Topical steroids are commonly used to treat eczema, as well as other skin conditions, such as acne and psoriasis.)
“When the person seems to be doing well and wants to stop treating the rash, upon withdrawal of the steroid medication, the area previously treated can become severely inflamed, sometimes even worse than the rash that was being treated,” Fromowitz says.
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Symptoms of TSW include red skin that burns, stings, cracks, peels, itches and displays pus-filled bumps. These generally begin to appear in the days and weeks after ceasing steroid treatment; recovery can take many months. Research into the condition is in the early stages, and not all dermatologists agree on the causes of TSW, how to diagnose it or even that it exists. (Some doctors say topical steroid withdrawal could be a flare-up of the condition the steroids were being used to treat.)
While the National Eczema Association (NEA) reports that the number of people affected by TSW is difficult to determine, the physicians we spoke with say that few people who use topical steroids will suffer from this complication. Michael Rogers, who practices family medicine in New Jersey, says that he frequently treats eczema patients — many of them with topical steroids — and has only once in his 40-year career seen a case of TSW. He says it was a severe case in a patient who had used topical steroids for most of her life and discontinued them when she decided to become pregnant. “It took a year for her symptoms to improve,” Rogers says.
According to the NEA, a review of medical literature on topical steroid withdrawal suggests that individuals who use topical steroids for extended, uninterrupted periods and who increase the amount and potency of the medication over time are most susceptible. “Typically, the higher the potency of the medication, the more likely this condition is to occur,” Fromowitz says. A 2015 review published in the Journal of the American Academy of Dermatology found that most reported cases were among women, with relatively few cases among patients ages 18 and younger. The face was the part of the body most prone to developing a rash or peeling from TSW.
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The surest way to avoid TSW is to not use topical steroids to treat eczema or other skin conditions, Fromowitz says, adding that they are the only thing that provides relief for many with severe eczema. According to the NEA website, topical steroids are effective and inexpensive, and they have been used to treat eczema for more than 50 years. Fromowitz says that a board-certified dermatologist can help a patient develop strategies to minimize the risk, including limiting the duration of steroid use or lowering the strength of the medication. “In recent years there have been nonsteroidal topical alternatives” that are approved by the Food and Drug Administration to treat eczema rashes, without the risk of TSW, he says.
Rogers recommends steps many people with mild to moderate eczema can take to help minimize symptoms on their own. “I tell the average eczema patient in the wintertime to stop with the long showers. The warmer the water the better it feels, but warmer water dries out the skin and tends to make it worse.” For those with a severe case of eczema, he recommends even turning the water off, lathering up, then turning it back on only to rinse.
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For those who are on topical steroids, he recommends “wet wrap therapy,” or placing a warm, damp cloth over the area to aid in absorption. According to the NEA, this can help the topical medications work better.
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