If you have eczema, psoriasis or another skin condition, you might use topical steroids. These corticosteroid creams or ointments can quickly reduce itching, redness and inflammation.
But what happens if your skin starts to depend on them? You could get a condition called topical steroid withdrawal (TSW) when you stop using these medications, especially after using them for a long time or in strong doses.
Paul Thompson, PharmD, a pharmacist with Banner Pharmacy Services, explained more about TSW, who’s at risk and how to work with your dermatology provider to safely manage your skin.
What is topical steroid withdrawal?
“TSW refers to a constellation of symptoms that may occur after you stop using topical corticosteroids if you’ve used them frequently or for a long time,” Dr. Thompson said.
It’s also known as:
- Red skin syndrome
- Steroid dermatitis
- Topical steroid addiction
It happens when your skin relies on topical steroids and has trouble adjusting once they’re stopped. It can cause burning, redness, peeling and intense itching. “Symptoms can often be more severe than the original skin condition,” Dr. Thompson said.
Who is at risk for topical steroid withdrawal?
Not everyone who uses topical steroids will have withdrawal symptoms. The risk can vary based on the condition you’re treating and how you’re using the medication.
The risk may be higher if you:
- Use moderate- or high-potency steroid creams, especially on sensitive areas
- Apply steroids daily or for long periods without breaks
- Use steroids on large parts of the body
- Use steroids on thin or sensitive skin, like the face or genitals (research has found that 99.3% of TSW cases happen in these sensitive areas)
- Have a history of atopic dermatitis
Children are at higher risk, since they may absorb more medication through the skin. And in adults, TSW occurs in women 81 percent of the time.
Signs and symptoms of topical steroid withdrawal
How can you tell if your skin is reacting to stopping steroid cream? “There are a range of symptoms with TSW,” Dr. Thompson said. Skin steroid withdrawal symptoms may include:
- Red, inflamed skin
- Burning, stinging or painful sensations
- Peeling, flaking or oozing skin
- Itching that doesn’t go away
- Skin that looks and feels worse than it did with the original condition
Dr. Thompson said you may notice these signs of steroid cream withdrawal:
- A “red sleeve” pattern with redness that stops at the wrists or ankles
- "Elephant wrinkles" or thick, wrinkled skin
- The "headlight sign" where your face is red but not your nose or mouth
TSW has two subtypes:
- The erythematoedematous type includes burning, redness and swelling
- The papulopustular type has pustules (pus-filled areas) and nodules (raised bumps or lumps)
Symptoms often show up days or weeks after stopping a topical steroid. How long does topical steroid withdrawal last? It can last for weeks or months.
Is it TSW or a flare-up of your skin condition?
“It can be hard to tell the difference between TSW and a flare of your condition,” Dr. Thompson said.
If your skin becomes suddenly worse, or if new symptoms appear after stopping steroids, get checked out. A dermatology provider can help see if it’s a flare-up or topical steroid withdrawal by checking:
- Whether your symptoms are part of your original skin condition
- If they’re related to stopping steroids too quickly
- Whether you’re experiencing topical steroid side effects
- What treatments are safe moving forward
It might be topical steroid withdrawal if:
- You notice more burning and stinging vs. itching
- Inflammation goes beyond the area that was affected at first
- You have signs like the red sleeve pattern, elephant skin or the headlight sign
- You’ve been increasing your use of steroids, especially on the face or genitals
What to do if you think you have topical steroid withdrawal
If you think topical steroid withdrawal is happening, you might think you should stop using steroids. But don’t take that step without talking to a health care provider. A sudden stop can make symptoms worse.
Everyone’s skin is different, and your plan should match your needs. It may help to:
- Taper off topical steroids slowly, following your health care provider’s advice
- Switch to lower-strength steroids
- Consider non-steroid treatments like calcineurin inhibitors or biologics like dupilumab
- Use moisturizers or emollients to support your skin
- Try cold compresses to help your skin feel better
- Consider antihistamines to help with itching
If your skin is open or crusty, your provider may check for infection and recommend an antibiotic.
“Psychological support is also crucial, as TSW can significantly impact mental health,” Dr. Thompson said.
Recent research has found that high levels of a coenzyme in cells may trigger TSW. In the future, targeted therapies like metformin and berberine may help treat the condition.
How to safely use topical steroids
Topical steroids are effective and safe when you use them correctly. To reduce the risk of withdrawal or side effects:
- Follow your provider’s instructions carefully
- Use the lowest strength that controls your symptoms
- Use only as long as needed
- Apply a thin layer to the affected area
- Use less often, such as twice a week instead of every day
- Don’t use them for a long time unless your provider says you should
- Ask about “steroid holidays” or taking breaks when possible
- Avoid high-strength steroids in sensitive areas
- Ask your provider how to use topical steroids and check in regularly
“TSW can be physically and emotionally debilitating,” Dr. Thompson said. “But it can be prevented by using corticosteroids correctly. Patients and providers should work together to balance the benefits of corticosteroids with the risks of overuse. Education, early recognition and access to supportive care are essential.”
When to see a dermatologist
A dermatologist can help you find safe and effective options for healing your skin. Make an appointment if:
- Your skin condition isn’t improving or is getting worse
- Symptoms get worse after you stop steroids
- You’re not sure whether your symptoms are a flare-up or TSW
- You have widespread or unusual skin symptoms
- You want to switch treatments or taper steroids safely
- You’re dealing with long-term skin irritation or scarring
“Dermatologists can help confirm TSW, rule out other conditions and guide tapering and other therapies,” Dr. Thompson said.
Why choose Banner Health for skin care?
At Banner Health, our dermatology team offers expert care for skin conditions like eczema, psoriasis, contact dermatitis and topical steroid withdrawal. Turn to us for:
- Personalized treatment plans tailored to your needs
- Support for tapering off steroids or switching medications
- Help managing your symptoms safely and effectively
Schedule an appointment online with a Banner Health dermatology provider to get expert care and guidance for your skin.
