Topical steroid use for skin conditions is the most common treatment available. You often hear doctors and patients sing their praises because it works. However, there are some downsides to topical steroid use if used improperly. One can develop a condition called topical steroid withdrawal (TSW) if a steroid is misused or abused. What can you do about it? First, let’s take a look at topical steroids.
What are Topical Steroids?
Topical steroids are commonly used to treat various dermatologic conditions. It’s one of the oldest treatment options and the most successful. However, this success has only been proved in certain conditions like psoriasis, vitiligo, eczema, atopic dermatitis, phimosis, lichen sclerosis, and acute radiation dermatitis. While it’s used in other conditions like melasma, chronic idiopathic urticaria, and alopecia areata, the evidence of success is limited.
There are dozens of topical steroids on the market. Each one differs in strength and formulation. The type of steroid you may need will depend on your diagnosis. The success of your treatment will depend on an accurate diagnosis, how often you’re required to apply the cream, how long you’re using it, the potency, the steroid’s delivery vehicle, and the side effects.
When you have a skin condition, your dermatologist or doctor will take a sample of the infected skin to determine the diagnosis. Sometimes, you may think it’s a skin condition when it may be a condition that requires an antifungal treatment. The doctor will scrape a section of your skin and apply potassium hydroxide to determine if antifungals are needed. Those that need steroids can benefit from the relief from inflammation, hyperproliferation, immunologic interference, burning, and pruritic lesions that the condition may cause.
When you suffer from a skin condition, you may need stronger steroids or a combination of several to treat it. The application of steroids will depend on the potency and the vehicle. In other words, the vehicle will depend on where the steroid is applied.
For example, ointments are great lubricators and occlusions. They are better suited to treat lesions or dry or thick areas of skin. The occlusion makes the steroid better absorb into the skin. However, ointments shouldn’t be applied to areas with hair. This can cause maceration or folliculitis if used on areas where the skin may touch like the groin or skin folds. Ointments tend to have a greasy finish which may make patients less likely to want to use them.
Lotions and gels apply to places that are hairy because they don’t matt and dry fairly quickly. Lotions are ideal for leaking lesions because many lotions contain alcohol that dries them. They also absorb nicely and leave little to no residue behind. Gels are ideal for inflammation conditions like poison ivy because they dry quickly, absorb, and can be applied to most of the body.
Creams lubricate well and soak into the skin. Creams typically aren’t as strong as ointments even when it’s the same steroid. They often contain preservatives that may irritate the skin or allergic reactions. Creams can be applied in areas where ointments can’t and are best suited for inflammation of the skin, but unlike ointments, lotions, and gels, creams aren’t occlusive.
It’s recommended that you apply your steroid after a shower or bath to increase absorption. Alternatively, you can apply a covering like plastic wrap for bedtime. Don’t apply a cover to areas of the face or areas where the skin touches to avoid irritation or infection.
Frequency of Application
Most conditions only require daily application once or twice a day. You don’t need to overapply. Increasing application won’t treat your condition quicker. Your doctor will go over how long you’re expected to use the steroids but universally it’s recommended that you don’t use them for more than three weeks. Chronic topical steroid use can result in topical steroid withdrawal or rebound effects. You want to taper down and take at least one week off steroids if you need to use them longer than three weeks.
What is Topical Steroid Withdrawal?
TSW is somewhat controversial among the medical community. It’s poorly understood but first emerged in a dermatology journal in 1979 and is now gaining widespread support. This condition refers to an adverse reaction you get after you stop using the steroid.
This typically happens after misuse or abuse of a moderate to high-potency steroid. Those that suffer from TWS have been reported to be over the age of 18, mostly female, and steroid use over 12 months with a daily or more often use. Those that correctly used steroids haven’t reported this condition.
What are the Symptoms of TSW?
There are very noticeable symptoms of TSW. The first symptoms that appear within days to weeks after discontinuing steroid use are redness and papulopustular rashes. The most common symptom described by those with the condition is burning or stinging of the skin.
Itchiness often accompanies once the dry scaly phase begins. Patients report their skin as more sensitive to moisturizers or the environment. Some may experience excessive sweating during the recovery phase. Some people may suffer from insomnia or fatigue, while others might develop an infection.
How to Diagnose
To receive a diagnosis these features need to be present:
A rash appears after stopping steroid use (use of steroid lasted for many months). Sometimes the rash is worse than the actual skin condition. The rash only appears where the steroid was applied at first. It may later spread to other areas.
Flare-ups from the skin condition and TWS might be hard to distinguish. Your doctor will consider TWS if you have burning rather than itchiness as the main symptom. Your redness isn’t patchy but confluent. Your rash is similar to atopic dermatitis but occurs in unusual places. You have a history of prolonged steroid use. Your doctor may perform skin biopsies or conduct allergy testing to rule out any other conditions or allergies.
How to Treat TSW
There’s no agreed-upon treatment for TSW. The only solution is to stop the topical steroid. You don’t need to taper off as the only type of steroid that has seen results with tapering is oral steroids. If you get an infection from a secondary infection, antibiotics might be required. Some helpful measures to ease discomfort come in the form of psychological support or cold compresses.
The solution is to stop relying on topical steroids for the management of symptoms. Also, to not use topical steroids too often on areas of the skin that are very thin (face, eyes, genitals), although the time frame is variable, some people can develop symptoms after only 5 days of using a potent steroid around the eyelid area.
How to Prevent TSW
The best way to prevent TSW is by avoiding the use of topical steroids for prolonged periods. The higher the potency of the steroid, the longer the application time, and the frequency of application make it more likely to develop TSW. Proper topical steroid use should be practiced to avoid it.
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