Topical steroid withdrawal
Other namesTopical steroid addiction, steroid dermatitis, red burning skin syndrome, red skin syndrome, iatrogenic exfoliative dermatitis (idiopathic erythroderma)[1]
Red burning skin syndrome from topical steroids. Face pattern with nose sign and spared palms (soles also spared)
SpecialtyDermatology
SymptomsRed skin, burning sensation, desquamation, itchiness[2]
CausesStopping topical steroids after frequent long-term use[2]
PreventionUsing steroid creams for less than two weeks[2][3]
FrequencyNot known[2]

Topical steroid withdrawal, also known as red burning skin and steroid dermatitis, has been reported in people who apply topical steroids for 2 weeks or longer and then discontinue use.[4][5][2][1] Symptoms affect the skin and include redness, a burning sensation, and itchiness,[2] which may then be followed by peeling.[2]

This condition generally requires the daily application of a topical steroid for more than 2 weeks but sometimes can occur with even less steroid use. It appears to be a specific adverse effect of topical corticosteroid use.[6] People with atopic dermatitis are most at risk.[3]

Treatment involves discontinuing the use of topical steroids,[2] either gradually or suddenly.[2] Counselling and cold compresses may also help.[2] The condition is common, with thousands of people congregating in online communities to support one another throughout the healing process. Many cases have been reported in both adults and children.[2][1] It was first described in 1979.[3]

Signs and symptoms

Red burning skin syndrome from topical steroids. Typical pattern on lower arms and hands

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.[7] When topical steroid medication is stopped, the skin experiences redness, burning, a deep and uncontrollable itch, scabs, hot skin, swelling, stinging, hives 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.[8] Topical steroid addiction has also been reported in the male scrotum area.[9] Other symptoms include nerve pain, insomnia, excessive sweating, anxiety, severe depression, fatigue, eye problems, and frequent infections.

Duration

The duration of acute topical corticosteroid withdrawal is variable; the skin can take months to years to return to its original condition.[2][10] 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

To experience this withdrawal, it generally requires the misuse and/or application of a topical steroid daily for 2 to 4 months, depending on the potency of the topical corticosteroid. In some cases, this has been reported after as little as 2 weeks of use.[11][1]

Mechanism of action

Historically, it was believed that cortisol was only produced by the adrenal glands, but research has shown that keratinocytes in human skin also produce cortisol.[12] Prolonged topical steroid (TS) application changes the glucocorticoid receptor (GR) expression pattern on the surface of lymphocytes; a patient experiencing resistance to a TS has 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.[1]

Diagnosis

Diagnosis is based on a rash occurring within weeks of stopping long-term topical steroids.[2] Specific signs include ‘headlight sign’ (redness of the lower part of the face but not the nose or the area around the mouth); ‘red sleeve’ (a rebound eruption stopping abruptly at the lower arms and hands); and ‘elephant wrinkles’ (reduced skin elasticity).[3]

Differentiating this condition from the skin condition that the steroids were originally used to treat can be difficult.[2] Red, burning skin may be misdiagnosed.[8]

Prevention

This condition can be avoided by not using steroid creams for periods of time longer than 2 weeks.[2][3]

Treatment

Treatment involves ceasing all use of topical steroids, either gradually or suddenly.[2] Keeping affected areas dry and disinfected will speed healing. Avoid moisturizer, as any dampness elongates the healing process and encourages bacterial growth. Antihistamines may help for itchiness.[3] Immunosuppressants and light therapy may also help some people.[3] Psychological support is often recommended.[2][3][11] 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.[13]

Epidemiology

This condition is not rare. Many cases ranging from mild to severe have been reported in both adults and children. One survey of atopic dermatitis patients treated with topical corticosteroids in Japan estimated that approximately 12% of adult patients may appear to be uncontrolled cases, although they are in fact addicted to a topical corticosteroid (TCS).[8]

History

A systematic review (meta-analysis) in accordance with evidence-based medicine frameworks and current research standards for clinical decision-making was performed in 2016 and was republished with updates in 2020.[14]

References

  1. 1 2 3 4 5 Juhász ML, Curley RA, Rasmussen A, Malakouti M, Silverberg N, Jacob SE (September–October 2017). "Systematic review of the topical steroid addiction and topical steroid withdrawal phenomenon in children diagnosed with atopic dermatitis and treated with topical corticosteroids". Journal of the Dermatology Nurses' Association. 9 (5): 233–240. doi:10.1097/JDN.0000000000000331. S2CID 80154596.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 "Topical corticosteroid withdrawal". DermNet NZ. Retrieved 19 July 2016.
  3. 1 2 3 4 5 6 7 8 Sheary B (June 2016). "Topical corticosteroid addiction and withdrawal - An overview for GPs". Australian Family Physician. 45 (6): 386–388. PMID 27622228.
  4. ↑ Nnoruka EN, Daramola OO, Ike SO (2007). "Misuse and abuse of topical steroids: implications". Expert Review of Dermatology. 2 (1): 31–40. doi:10.1586/17469872.2.1.31. Retrieved 2014-12-18.
  5. ↑ Rathi SK, D'Souza P (July 2012). "Rational and ethical use of topical corticosteroids based on safety and efficacy". Indian Journal of Dermatology. 57 (4): 251–259. doi:10.4103/0019-5154.97655. PMC 3401837. PMID 22837556.
  6. ↑ Hajar T, Leshem YA, Hanifin JM, Nedorost ST, Lio PA, Paller AS, et al. (March 2015). "A systematic review of topical corticosteroid withdrawal ("steroid addiction") in patients with atopic dermatitis and other dermatoses". Journal of the American Academy of Dermatology. 72 (3): 541–549.e2. doi:10.1016/j.jaad.2014.11.024. PMID 25592622.
  7. ↑ Smith MC, Nedorost S, Tackett B (September 2007). "Facing up to withdrawal from topical steroids". Nursing. 37 (9): 60–61. doi:10.1097/01.NURSE.0000287732.08659.83. PMID 17728660.
  8. 1 2 3 Fukaya M, Sato K, Sato M, Kimata H, Fujisawa S, Dozono H, et al. (2014). "Topical steroid addiction in atopic dermatitis". Drug, Healthcare and Patient Safety. 6: 131–138. doi:10.2147/dhps.s69201. PMC 4207549. PMID 25378953.
  9. ↑ Kling C, Obadiah J (2005-03-01). "Corticosteroid-dependent scrotum". Journal of the American Academy of Dermatology. 52 (3): P47. doi:10.1016/j.jaad.2004.10.202. ISSN 0190-9622.
  10. ↑ "Topical steroid addiction: Calls for more support for patients". BBC News. March 2021.
  11. 1 2 Ghosh A, Sengupta S, Coondoo A, Jana AK (September 2014). "Topical corticosteroid addiction and phobia". Indian Journal of Dermatology. 59 (5): 465–468. doi:10.4103/0019-5154.139876. PMC 4171914. PMID 25284851.
  12. ↑ Cirillo N, Prime SS (June 2011). "Keratinocytes synthesize and activate cortisol". Journal of Cellular Biochemistry. 112 (6): 1499–1505. doi:10.1002/jcb.23081. PMID 21344493. S2CID 22289437.
  13. ↑ Lio PA (August 2019). "Topical Steroid Withdrawal in Atopic Dermatitis". Practical Dermatology.
  14. ↑ Hwang J (25 Dec 2020). "Topical corticosteroid withdrawal ('steroid addiction'): an update of a systematic review". Journal of Dermatological Treatment. 33 (3): 1293–1298. doi:10.1080/09546634.2021.1882659. PMID 33499686. S2CID 231764481.
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