Topical steroid withdrawal is a skin condition that can develop when someone uses potent topical steroids frequently and for a long time.
What is topical steroid withdrawal?
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.
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.
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."
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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.
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.
- 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.
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.
- 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 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. 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. 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.
Using topical steroids more frequently or for a longer duration than recommended
This may cause topical steroid withdrawal. 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
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. 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.
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.
- 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.
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.
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.
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
- 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?
Self-diagnose with our free Buoy Assistant if you answer yes on any of these questions.
Male, 14-15, I started in December, not knowing I couldn’t just put it anywhere. I had a little rash on my mustache area, above my top lip. I applied it only a few times from what I remember, right after a shower, or when I was looking at it in the mirror. Everything was great at first, until about 2 to 2 1/2 weeks after putting it on. It was really really red. I was in school at the time, right before Winter Break. It was embarrassing and I had looks from people like I was dying or a monster. Flash forward to present, and it’s still there, still red, but not as red. It breaks out when I eat something I’m allergic to. It’s a repeated cycle of impetigo on my face. It tries to spread to my other eczema sites, but I either put antibiotic ointments on it or wash it up with soap in the sink or the shower. Now I've learned to always double check before I put something on my skin.
I have been using a particular steroid cream to deal with my acne for five years and my skin has gotten thin as a result of overusing it. Three days ago, my face became red with pus-filled bumps and got really painful with a stinging sensation. I can’t look in the mirror without crying. I have discontinued use, but I wish there was something I could do to ease the painful burning sensation. I wish I hadn't started using corticosteroids in the first place, but I was happy with the results it gave me. Please help me.
Female 26 AI I have been using steroids my whole life. In 2014 I did the clinical trails and cleared my eczema. But coming off the trial I couldn’t get Dupixent covered and could not afford it. They put me back on steroid cream and that did not work. I started to develop red skin syndrome and then they gave me a month dose of prednisone. I never did the pills for that long, came off them and went into a bad rebound. I then did the injection in my arm. The whole time i was telling them the steroid made me worse. I’ve been going through tsw for 1 year now and stopped steroids about 7 months ago. I’m also on Dupixent. It just sucks the doctors won’t listen and my derm just prescribes more steroids, even after I explained the burning red skin. It looked like my skin was attacking itself and falling off, but I was constantly told it was bad eczema, and no one asked how I was doing. Depression set in and no doctor would even ask. I explained how I couldn't leave my house and that I would cry looking at myself in the mirror and the swelling on my ankles and pain shooting through my feet to my legs. So finally I stopped trying to find a doctor who would help and went the traditional Chinese medical way. No one understood the sleepless nights, the oozing and burning, the no control over my temperature and then not being able to walk because the pain was too much the bear. My first panic attack happened when I ran out of cream and everyone in my family was sleeping.
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