Topical Steroid Withdrawal Symptoms, Causes & Treatment Options

Topical steroid withdrawal is a skin condition that can develop when someone uses potent topical steroids frequently and for a long time.

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Contents

  1. Overview
  2. Symptoms
  3. Potential Causes
  4. Treatment, Prevention and Relief
  5. When to Seek Further Consultation
  6. Questions Your Doctor May Ask
  7. References

What Is Topical Steroid Withdrawal?

Summary

Topical steroid withdrawal is a skin condition that can develop when someone uses potent topical steroids frequently and for a long time. The condition can manifest within days to weeks after you stop using topical steroids, or it can manifest as a worsening rash that requires stronger and more frequent application of topical steroids to control [1].

One of two main types of rashes may develop with topical steroid withdrawal at the sites of application. One type is red, swollen, scaly and peeling, and the other is defined by red, pus-filled bumps without scaling or peeling. The skin may also be burning, stinging, or itchy, and you may experience facial hot flashes.

Treatments include discontinuing the troublesome medication as well as methods to soothe associated symptoms.

Recommended care

You should go see your primary care doctor to talk about stopping use of the steroid. Your doctor may prescribe a medication like antibiotics, antihistamines, or cool compresses to help heal along with testing the skin with what's called "patch testing."

Topical Steroid Withdrawal Symptoms

Topical steroid withdrawal symptoms usually develop within days to weeks after stopping a topical steroid medication. In general, people who develop topical steroid withdrawal can develop one of two main types of rashes: erythematoedematous ("red and swollen") and papulopustular ("bumpy"). The rashes are usually limited to the areas of skin where topical steroids were applied, and more often affect the face or genital areas because of the thinner skin in these areas.

These two types of rashes, as well as other symptoms seen in topical steroid withdrawal, are described below.

Erythematoedematous rash

People with topical steroid withdrawal who develop the erythematoedematous form of rash will experience the following. This type of rash is seen more commonly in people who used the topical steroid for an underlying skin condition such as atopic dermatitis (eczema) or seborrheic dermatitis [1].

  • Redness and swelling of the skin: This will be at the site of topical steroid application.
  • Skin that is scaly or peeling
  • Red bumps may or may not be present
  • Defined rash border: In some people who develop this type of rash on the face, there may be a sharp cutoff between the red and normal-appearing parts of the skin, with sparing of the nose and ears.

Papulopustular rash

People with topical steroid withdrawal who develop the papulopustular form of rash will experience the following. This type of rash is seen more commonly in people who used the topical steroids for acne or for cosmetic appearances [1].

  • Redness with prominent red bumps and pus-filled bumps: These will appear over the area of topical steroid application.
  • Less prominent swelling
  • No skin peeling

Other symptoms

Other symptoms associated with topical steroid withdrawal include the following.

  • Burning and stinging of the skin: Most people experience a burning and stinging sensation over the skin where the topical steroid was applied. This is usually more prominent in the erythematoedematous type of rash than in the papulopustular type of rash. In some cases, the skin may feel outright painful. The burning and stinging may be exacerbated with exposure to heat or the sun.
  • Itchy skin: Some people with topical steroid withdrawal may also experience itching of the skin where topical steroids were applied. Itching usually follows a period of burning and stinging and occurs once the redness starts to fade. The itching may be severe enough to interfere with sleep.
  • Facial hot flashes: Some people who develop topical steroid withdrawal on the face may experience episodes of hot flashes. When these episodes occur, their face will flush red and may feel warm.

Topical Steroid Withdrawal Causes

Topical steroid withdrawal usually occurs in adults older than 18 years old and has been reported more frequently in women [2]. Most people who use topical steroids as directed do not get topical steroid withdrawal. Risk factors for developing topical steroid withdrawal include using mid- or high-potency steroids, using topical steroids more frequently or for a longer duration than recommended and using topical steroids on the face or groin region.

Using mid- or high-potency topical steroids

Most cases of topical steroid withdrawal have been described in people who use mid- or high-potency topical steroids [3]. Topical steroids can be more potent due to the specific steroid in the medication, the concentration of steroid in the medication, and/or the formulation of the medication. For example, creams and ointments tend to be stronger than lotions and solutions. Examples of mid- and high-potency topical steroids include triamcinolone 0.1 to 0.5% cream or ointment (Kenalog), mometasone 0.1% cream or ointment (Elocon), fluocinonide 0.05% cream or ointment (Lidex), desoximetasone 0.25% cream or ointment (Topicort), or clobetasol 0.05% cream or ointment (Temovate), among others [4].

Using topical steroids more frequently or for a longer duration than recommended

This may cause topical steroid withdrawal [5]. High-potency topical steroids are typically not to be used more than once daily, and for no longer than three weeks at a time. In some cases, your physician may recommend using a mid- or high-potency topical steroid intermittently, such as twice a week as maintenance therapy. In addition, most physicians will recommend tapering the topical steroid once the skin condition has resolved. Most people who develop topical steroid withdrawal use topical steroids daily and for more than 12 months.

Using topical steroids on the face or groin regions

Using topical steroids on the face or groin regions increases the risk of developing topical steroid withdrawal. This is because the skin on the face and groin regions is thinner and absorbs topical steroids more easily, predisposing the individual to develop topical steroid withdrawal in those areas.

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Treatment Options and Prevention

Treatment for topical steroid withdrawal involves discontinuing the use of topical steroid medications and managing the symptoms of the withdrawal [6,7]. Specific treatment options include:

Discontinue the use of topical steroid medications

In most cases of topical steroid withdrawal, the first step in treatment is to discontinue the use of topical steroid medications. Some physicians may recommend tapering the topical steroid slowly, due to concern that stopping the topical steroid suddenly may worsen the withdrawal symptoms [6]. However, other physicians may recommend stopping the topical steroid suddenly once withdrawal symptoms develop since some studies show no difference between stopping suddenly and stopping gradually.

Apply ice or cool compresses

Some physicians may recommend applying ice or cool compresses to the skin to alleviate stinging, burning, or itching.

Antihistamine medications

People with steroid withdrawal syndrome who experience significant itching may benefit from antihistamine medications, which prevent the body from releasing substances that contribute to the itching. The doctor may recommend one of two types of antihistamines [8].

  • First-generation antihistamines: diphenhydramine (Benadryl), dimenhydrinate (Dramamine), and hydroxyzine (Atarax) have sedating effects in addition to anti-itching effects and may be helpful for people who have trouble sleeping due to itching.
  • Second-generation antihistamines: cetirizine (Zyrtec), loratadine (Claritin), Allegra and desloratadine (Clarinex) have less sedating effects and may be helpful for people who don't want to have sedating side-effects.

Antibiotics

Some people with steroid withdrawal syndrome may benefit from a course of certain antibiotic medications, such as tetracycline, doxycycline, or erythromycin. These antibiotic medications have anti-inflammatory effects as well, and therefore may be helpful in controlling symptoms. Antibiotic medications are more often used for people with the papulopustular type of rash.

A short course of oral steroids

Some physicians may recommend that people with topical steroid withdrawal complete a short course of oral steroid medications, such as prednisolone. Topical steroid withdrawal is only due to the excess use of topical steroids, so a course of oral steroids would not worsen the symptoms and may help by reducing inflammation throughout the body.

Psychological support

Because steroid withdrawal syndrome can cause a fair amount of distress due to the symptoms and the appearance of the rash, some people with steroid withdrawal syndrome may benefit from psychological support such as counseling [1,9].

When to Seek Further Consultation

If you develop any symptoms of topical steroid withdrawal after using topical steroids, you should see your physician. He or she can determine if your symptoms such as skin redness, swelling, burning, or itching, are in fact due to topical steroid withdrawal.

Questions Your Doctor May Ask to Diagnose

To diagnose this condition, your doctor would likely ask about the following symptoms and risk factors.

  • Is your rash raised or rough when touching it?
  • Is your skin change constant or come-and-go?
  • How long have your skin changes been going on?
  • Are there bumps on your rash?
  • Any fever today or during the last week?

If you've answered yes to one or more of these questions

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References

  1. Education announcement: Use of topical steroids for eczema. National Eczema Association. National Eczema Association Link
  2. Dhossche J, Simpson E, Hajar T. Topical corticosteroid withdrawal in a pediatric patient. JAAD Case Reports. 2017;3(5):420-1. NCBI Link
  3. Coondoo A, Phiske M, Verma S, Lahiri K. Side-effects of topical steroids: A long overdue revisit. Indian Dermatology Online Journal. 2014;5(4):416-425. NCBI Link
  4. What's tops in, topical steroid treatments? National Psoriasis Foundation. NPF Link
  5. Eczema: Steroids and other topical medications. Informed Health Online. Published February 23, 2017. NCBI Link
  6. Fukaya M, Sato K, Sato M, et al. Topical steroid addiction in atopic dermatitis. Drug, Healthcare and Patient Safety. 2014;6:131-8. NCBI Link
  7. Sheary B. Topical corticosteroid addiction and withdrawal - an overview for GPs. The Royal Australian College of General Practitioners. 2016;45(6):386-8. RACGP Link
  8. Mann RD, Pearce GL, Dunn N, Shakir S. Sedation with "non-sedating" antihistamines: Four prescription-event monitoring studies in general practice. The BMJ. 2000;320(7243):1184-7. NCBI Link
  9. Ghosh A, Sengupta S, Coondoo A, Jana AK. Topical corticosteroid addiction and phobia. Indian Journal of Dermatology. 2014;59(5):465-8. NCBI Link