How to Avoid Topical Steroid Addiction and Topical Steroid Withdrawal
Image source: https://dermnetnz.org/topics/topical-steroidWhat are topical steroids?
Steroids regulate growth and inflammation in our body. Corticosteroids, the type of steroid used to treat eczema, reduces inflammation. Topical steroids are corticosteroids that are applied to the skin, they mimic the natural steroid, cortisol, made by our body to counteract inflammation (🔗). Unfortunately in eczema the natural levels of cortisol cannot keep inflammation in check. Hence topical corticosteroids (TCS) can be a supplement to help calm the inflamed skin and reduce itch.
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Topical steroids work by passing into our cells and binding to sections of DNA. This has the effect of switching off the production of proteins that cause inflammation (known as cytokines, for example, interleukin 4 or IL4) (🔗). Steroids are cheap and effective, which is why they have proved so popular for eczema.
Topical steroids offer short term relief for a chronic (long lasting) disease, so balancing eczema relief with overuse is challenging. Because TCS are so effective and accessible it’s tempting to use more, resulting in our skin cells becoming accustomed to their presence. This can lead to topical steroid withdrawal when steroids are stopped abruptly.
What is Topical Steroid Withdrawal / Topical Steroid Addiction?
Topical steroid withdrawal (TSW), also known as red skin syndrome or topical steroid addiction, occurs when topical steroids are stopped and the skin cells readjust to the natural, much lower, levels of steroid provided by our body. Because steroids cause microscopic blood vessels in our skin to constrict (get smaller), when they are stopped the blood vessels dilate (get bigger) and the extra blood flow can make skin look red and feel hot: inflammation returns along with itching and burning (🔗). The symptoms of TSW are very similar to eczema. So how do you tell the difference?
What is the difference between eczema and TSW?
Caregivers may be looking for signs of TSW when they stop using topical steroids. Remember that when stopping steroids the eczema can return, but that doesn't mean that TSW is occurring. To understand the difference, we asked Dr. Helen Brough, Director of Children’s Allergy Doctors in London, to explain. She says that, “TSW symptoms include burning, stinging, and redness that spreads beyond the original eczema area,” she adds. “You can see shiny or swollen skin, and this often occurs in a cycle when the redness and discomfort worsens when stopping the topical steroids abruptly.”
The differences are subtle, but if you know what to look for, you should be able to spot the difference. More details can be found on the UK National Eczema Society statement. So, how can a caregiver decide if steroids are right for their child?
Should I use steroids on my child?
Many caregivers question if they should use topical steroids at all for their child’s eczema. Sandra Lawton, an experienced pediatric nurse who specialises in eczema says, “in clinical practice, we don't routinely see side effects [from topical steroids]. The benefit is your child's eczema will be under control. It will improve their quality of life, they will sleep better, they can participate in activities”. She adds that, “the [2022 Cochrain] review did show that topical steroids are safe, and it's important to treat and prevent flares of eczema safely and effectively with the topical steroids alongside using emollients.”
Dr. Brough also points out that, “In children under three years of age, TSW is virtually unheard of.”
The risks of not treating eczema
By choosing not to treat eczema Dr. Brough points out that untreated eczema allows, “pathogens like bacteria, viruses or fungi to enter the skin and lead to more severe eczema.” In addition, “bacteria on the skin of infected eczema, Staphylococcus aureus, produces a toxin that makes the immune system on the skin much more likely to see something innocuous, like peanut, as a pathogen, and then respond to it in allergic way.” This increases the risk of future food allergies.
To sum up, it’s better to treat eczema with topical steroids to reduce the risk of infection and food allergies. The important thing is to know how to use steroids safely.
How to use steroids safely to avoid TSW developing
Caregivers are concerned about TSW, and justifiably so, because it could result in greater suffering if topical steroids are over used. However, topical steroids can be used safely on eczema children, the important thing is to have a plan.
Only apply topical steroids once per day. Research shows that more frequent applications are not more effective (🔗).
Dr. Brough’s advice is to apply steroids once a day, “until the skin flare is controlled, and thereafter twice a week to prevent recurrence of the eczema flare. Apply it only to the areas of the skin that the eczema is inflamed. And make sure that the lowest potency is being used for the shortest possible time to calm the skin down”. Once the flare is controlled, she recommends, “Using the topical anti-inflammatory twice a week for up to 16 weeks to prevent recurrence of the eczema flare.”
If you are feeling trapped in a cycle of using steroids to ease your child's suffering then watching it rebound, it might help to have a wall chart so you can tick the days you use steroids (🔗), then build in breaks (🔗) as recommended by your prescribing care provider.
Remember: (1) follow your care providers instructions, (2) keep a record of usage, and (3) build in breaks. This way your child can safely use steroids to relieve their eczema.
What if my care provider prescribes steroids?
If your care provider prescribes topical steroids, raise any concerns you have and ask them about the risks and benefits. Specifically ask them how their plan will mitigate the risks of TSW, and ensure you have a follow up appointment booked to revise your child's eczema plan.
Here are some questions to ask:
What are the pros and cons of using steroids?
How will my care plan lower the chance of TSW occurring?
What do I do if the topical steroids aren’t working?
Are there alternatives to topical steroids, and when should I consider alternatives?
When will we review this care plan?
Types of topical steroids available. Source: https://www.mcgill.ca/peds/files/peds/steroid_chart_md_2021.pdfWhat are the alternatives to topical steroids?
Steroids are used to reduce skin inflammation, but make sure you are doing everything possible to help the skin before using steroids. The first step is to strengthen the skin barrier by moisturizing daily and especially (immediately) after bathing. “Daily emollient use led to a 32% reduction in the number of flares requiring topical steroids”, says Dr. Brough. For detailed moisturizing tips, see our previous blog.
The second step is to reduce the inflammation. If you choose not to use steroids to reduce inflammation, then other anti-inflammatory treatments are available. These include:
Topical calcineurin inhibitors: Tacrolimus ointment (Protopic) from 2 years or Pimecrolimus cream (Elidel) from 3 months.
PDE4 inhibitors: Crisaborole (Eucrisa) from 3 months or Roflumilast (Zoryve) from 2 years.
Topical JAK inhibitors such as Ruxolitinib (Opzelura) from 2 years.
AhR agonist Tapinarof (Vtama) from 2 years.
Your care provider can explain the risks and benefits of these alternatives to topical steroids.
Step three, regularly check GPER’s treatment navigator for up to date details on the safety and adverse reactions to these alternatives and any newer treatments that are currently being tested.
Other risks of topical steroids for eczema
Although being a cheap and effective first line therapy, steroids aren’t risk free. Beyond TSW, long term use of steroids, can cause skin thinning, stretch marks, bruising, and excessive hair growth. More serious concerns are slowed growth, reduced eye health, lower cortisol production, or Cushing's syndrome (🔗). Discuss any concerns with your care provider, especially if you are prescribed potent steroids or you are using them in sensitive areas like the face and genitals.
Next steps
Ensure you’re doing the best for your child’s skin before resorting to steroids. Check, are you:
Moisturizing twice daily
Keeping their baths cool and short
Avoiding harsh soaps
Doing research beyond social media: it tends to be motive driven or highlight extreme scenarios. (GPER provides evidence based information, and Eczhale is an invaluable resource for eczema caregivers.)
Using the treatment exactly as prescribed by your care provider, fully aware of the risks and benefits
Following up with your care provider to assess treatment success
It’s not easy making medical decisions for your child, but reading this means you care. Your child is lucky to have you on their side. Just don’t forget to be kind to yourself too, you deserve it. Subscribe to our newsletter to stay in the loop about helpful topics like these! www.gper.org/newsletter.
AI statement: This blog was written entirely by a human, without the use of AI generative text.
Written by: Lynita Howie, MPhil, Global Parents for Eczema Research
