Topical corticosteroids, or topical steroids for short, are commonly prescribed to manage various skin conditions, including eczema (atopic dermatitis) and psoriasis. Although they’re effective, excessive use has its consequences, warns Dr Suretha Kannenberg, who explains the ins and outs of topical steroid addiction and withdrawal.
Topical steroidal medications are effective in reducing inflammation and controlling symptoms. However, prolonged use can lead to a condition known as topical steroid addiction (TSA), which may result in topical steroid withdrawal (TSW) upon cessation.
Let’s explore these phenomena, their causes, symptoms, and ways to manage them.
What is topical steroid addiction?
TSA occurs when the skin becomes dependent on the medication. Over time, the skin builds a tolerance, requiring higher, more frequent doses or more potent steroids to achieve the same effect, potentially leading to adverse effects. This dependency makes it difficult to stop using the medication without experiencing a rebound flare, during which symptoms return worse than before.
Several factors contribute to the development of TSA:
- Prolonged use: Using topical steroids for an extended period increases the risk of addiction.
- High potency: More potent topical steroids have a higher likelihood of causing addiction; however, mild, over-the-counter topical steroids can also occasionally lead to TSA.
- Frequent application: Applying steroids more frequently than prescribed can lead to dependency.
- Sensitive skin areas: Using steroids on thinner skin areas, such as the face, genitals, or flexures, can increase the risk due to higher absorption rates.
What is topical steroid withdrawal?
TSW refers to the severe flare-ups and skin reactions that occur when someone stops using topical steroids after long-term application. This condition, also known as red skin syndrome, can be extremely challenging both physically and emotionally.
TSW may follow the use of topical steroids for the correct indications, such as for eczema and psoriasis, but may also follow the inappropriate use thereof, such as for skin lightening. The latter comprises the vast majority of cases of TSW.
In people with a background of skin disease, removing the topical steroid from the treatment regime will inadvertently lead to a flare-up of the disease – often characterised by red, hot, and scaly skin. Distinguishing between this and TSW can be very challenging, and these conditions may even co-occur.
Symptoms and signs of topical steroid withdrawal
The symptoms associated with TSW may vary widely but often include:
- Red and glazy inflamed skin: Extensive redness and inflammation (hence the alternative name of TSW being red skin syndrome). This often extends beyond the area of application.
- Severe itching: Intense itching that can be debilitating.
- Burning sensation: A constant burning feeling in the skin. This is a stronger indicator of TSW than itching and also tends to spread beyond the area of application.
- Peeling and flaking: Peeling, flaking, or shedding of the skin may occur in large amounts. This can be very difficult, or near impossible, to distinguish from an underlying skin disorder.
- Oozing and crusting: Weeping and crusting of the skin, leading to potential infections.
- Swelling: Significant swelling, especially around the eyes and face.
- Systemic features such as insomnia and fatigue: Difficulty sleeping due to discomfort, leading to fatigue. Menstrual irregularities and hair loss are not uncommon. The emotional impact on the patient, as well as the whole family, cannot be underestimated.
Managing topical steroid withdrawal
Managing TSW requires patience and a comprehensive approach that entails the following aspects:
- Medical supervision: Always consult a healthcare professional before discontinuing topical steroids. This is a reasonably newly recognised condition, so it may be challenging to find the right healthcare practitioner to assist in the withdrawal period. The right practitioner can guide you through the process and suggest alternative treatments. Keep in mind that the withdrawal period may be quite a lengthy one, so don’t rush it.
- Gradual tapering: Gradually reducing the steroid strength and application frequency can help minimise withdrawal symptoms.
- Moisturising: Keeping the skin well moisturised can alleviate dryness and discomfort, relieving the itch in the process. Make sure to stick to gentle, fragrance-free moisturisers. Avoid soaps that foam and rather stick to soap-free cleansers. Specialised soap substitutes and moisturisers for eczema-prone skin may be found on the Allergy Foundation of South Africa’s website and are advisable.
- Cold compresses: Applying cold compresses can reduce inflammation and provide temporary relief.
- Supportive care: Consider seeking support from online communities or support groups. Connecting with a mental healthcare professional is also advised for maintaining emotional and mental well-being. Sharing experiences and advice can be invaluable during this challenging time.
- Alternative therapies: Explore non-steroidal treatments such as calcineurin inhibitors or other prescription medications that may help control symptoms without the risks associated with steroids.
Preventing topical steroid addiction
As with everything: prevention is better than cure. Here are a few steps you can take to prevent TSA:
- Follow prescriptions: Use topical steroids exactly as prescribed by your healthcare provider. Avoid self-medicating or increasing doses without professional guidance.
- Limit duration: Use the lowest effective dose for the shortest duration necessary.
- Regular reviews: Regularly review your treatment plan with your healthcare provider to ensure it’s still appropriate.
- Alternative treatments: Consider non-steroidal options for managing chronic skin conditions. Phototherapy or immunosuppressants may be viable alternatives.
In conclusion
Topical steroid addiction and topical steroid withdrawal are serious conditions that can significantly impact quality of life. Awareness and education are key to preventing and managing these issues.
If you suspect you are experiencing TSA or TSW, seek medical advice promptly.
With the right approach, it is possible to manage symptoms and maintain healthy skin without the reliance on topical steroids.
MBChB (Stell), MMed Derm (Stell)
Dr Suretha Kannenberg is a consultant dermatologist at the division of Dermatology at the University of Stellenbosch, Tygerberg Academic Hospital. She also has a private practice in the Northern Suburbs of Cape Town.
She earned her medical degree (MBChB) and Master’s degree in Dermatology (MMed Dermatology) cum laude from the University of Stellenbosch.
Dr Kannenberg serves on the executive committees of the Dermatological Society of South Africa (DSSA), the African Women's Dermatologic Society (AWDS) and the Vitiligo Society of South Africa (VSSA).
She has authored a number of publications and book chapters and features regularly in the media in public awareness campaigns. She gives lectures locally and internationally on topics close to her heart. These include atopic dermatitis, vitiligo, acne vulgaris and paediatric dermatology. She is actively involved in a number of community projects in South Africa and spearheads patient support groups in atopic eczema and vitiligo.