Topical steroid withdrawal

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Topical steroid withdrawal
Other namesTopical steroid addiction, steroid dermatitis, red burning skin syndrome, red skin syndrome, iatrogenic exfoliative dermatitis (idiopathic erythroderma) [1]
Red (burning) Skin Syndrome - Showing Face Pattern with white nose sign and spared palms (soles spared too).jpg
Red burning skin syndrome from topical steroids. Face pattern with nose sign and spared palms (soles also spared)
Specialty Dermatology
Symptoms Red skin, burning sensation, desquamation, itchiness [2]
CausesStopping topical steroids after frequent long-term use [2]
PreventionUsing steroid creams for less than two weeks [2] [3]
FrequencyNot known [2]

Topical steroid withdrawal, also known as red burning skin and steroid dermatitis, has been reported in people who apply topical steroids for 2 weeks or longer and then discontinue use. [4] [5] [2] [1] Symptoms affect the skin and include redness, a burning sensation, and itchiness, [2] which may then be followed by peeling. [2]

Contents

This condition generally requires the daily application of a topical steroid for more than 2 weeks but sometimes can occur with even less steroid use. It appears to be a specific adverse effect of topical corticosteroid use. [6] People with atopic dermatitis are most at risk. [3]

Treatment involves discontinuing the use of topical steroids, [2] either gradually or suddenly. [2] Counselling and cold compresses may also help. [2] Thousands of people congregate in online communities to support one another throughout the healing process, and cases have been reported in both adults and children. [2] [1] It was first described in 1979. [3]

Signs and symptoms

Red burning skin syndrome from topical steroids. Typical pattern on lower arms and hands Red (burning) Skin Syndrome - Typical Pattern of Lower Arms & Hands.jpg
Red burning skin syndrome from topical steroids. Typical pattern on lower arms and hands

Topical steroid addiction (TSA) is characterised by uncontrollable, spreading dermatitis and worsening skin inflammation, which requires a stronger topical steroid to get the same result as the first prescription. This cycle is known as steroid addiction syndrome. [7] When topical steroid medication is stopped, the skin experiences redness, burning, a deep and uncontrollable itch, scabs, hot skin, swelling, stinging, hives and/or oozing for a length of time. This is also called 'red skin syndrome' or 'topical steroid withdrawal' (TSW). After the withdrawal period is over, the atopic dermatitis can cease or is less severe than it was before. [8] Topical steroid addiction has also been reported in the male scrotum area. [9] Other symptoms include nerve pain, insomnia, excessive sweating, anxiety, severe depression, fatigue, eye problems, and frequent infections.

Duration

The duration of acute topical corticosteroid withdrawal is variable; the skin can take months to years to return to its original condition. [2] [10] The duration of steroid use may influence the recovery factor time, with the patients who used steroids for the longest reporting the slowest recovery.

Cause

To experience this withdrawal, it generally requires the misuse and/or application of a topical steroid daily for 2 to 4 months, depending on the potency of the topical corticosteroid. In some cases, this has been reported after as little as 2 weeks of use. [11] [1]

Mechanism of action

Historically, it was believed that cortisol was only produced by the adrenal glands, but research has shown that keratinocytes in human skin also produce cortisol. [12] Prolonged topical steroid (TS) application changes the glucocorticoid receptor (GR) expression pattern on the surface of lymphocytes; a patient experiencing resistance to a TS has a low ratio of GR-α to GR-β. In addition, the erythema characteristic of ‘red skin syndrome’ is due to a release of stored endothelial nitric oxide (NO) and subsequent vasodilation of dermal vessels. [1]

Diagnosis

Diagnosis is based on a rash occurring within weeks of stopping long-term topical steroids. [2] Specific signs include ‘headlight sign’ (redness of the lower part of the face but not the nose or the area around the mouth); ‘red sleeve’ (a rebound eruption stopping abruptly at the lower arms and hands); and ‘elephant wrinkles’ (reduced skin elasticity). [3]

Differentiating this condition from the skin condition that the steroids were originally used to treat can be difficult. [2] Red, burning skin may be misdiagnosed. [8]

Prevention

This condition can be avoided by not using steroid creams for periods of time longer than 2 weeks. [2] [3]

Treatment

Treatment involves ceasing all use of topical steroids, either gradually or suddenly. [2] Keeping affected areas dry and disinfected will speed healing.[ citation needed ][ dubious – discuss ] Avoid moisturizer, as any dampness elongates the healing process and encourages bacterial growth.[ citation needed ][ dubious – discuss ] Antihistamines may help for itchiness. [3] Immunosuppressants and light therapy may also help some people. [3] Psychological support is often recommended. [2] [3] [11] At this time, treatment options that have been documented in literature include Tacrolimus, Pimecrolimus, and Dupixent. Some physicians have also seen positive outcomes with oral Doxycycline and/or topical Clindamycin. [13]

Epidemiology

The prevalence of the condition is unknown. [14] Many cases ranging from mild to severe have been reported in both adults and children. One survey of atopic dermatitis patients treated with topical corticosteroids in Japan estimated that approximately 12% of adult patients may appear to be uncontrolled cases, although they are in fact addicted to a topical corticosteroid (TCS). [8]

History

A systematic review (meta-analysis) in accordance with evidence-based medicine frameworks and current research standards for clinical decision-making was performed in 2016 and was republished with updates in 2020. [15]

Related Research Articles

<span class="mw-page-title-main">Dermatitis</span> Inflammatory disease of the skin

Dermatitis is inflammation of the skin, typically characterized by itchiness, redness and a rash. In cases of short duration, there may be small blisters, while in long-term cases the skin may become thickened. The area of skin involved can vary from small to covering the entire body. Dermatitis is often called eczema, and the difference between those terms is not standardized.

<span class="mw-page-title-main">Corticosteroid</span> Class of steroid hormones

Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are involved in a wide range of physiological processes, including stress response, immune response, and regulation of inflammation, carbohydrate metabolism, protein catabolism, blood electrolyte levels, and behavior.

<span class="mw-page-title-main">Cortisone</span> Corticosteroid precursor and metabolite of cortisol

Cortisone is a pregnene (21-carbon) steroid hormone. It is a naturally-occurring corticosteroid metabolite that is also used as a pharmaceutical prodrug. Cortisol is converted by the action of the enzyme corticosteroid 11-beta-dehydrogenase isozyme 2 into the inactive metabolite cortisone, particularly in the kidneys. This is done by oxidizing the alcohol group at carbon 11. Cortisone is converted back to the active steroid cortisol by stereospecific hydrogenation at carbon 11 by the enzyme 11β-Hydroxysteroid dehydrogenase type 1, particularly in the liver.

<span class="mw-page-title-main">Seborrhoeic dermatitis</span> Skin disease

Seborrhoeic dermatitis is a long-term skin disorder. Symptoms include flaky, scaly, greasy, and occasionally itchy and inflamed skin. Areas of the skin rich in oil-producing glands are often affected including the scalp, face, and chest. It can result in social or self-esteem problems. In babies, when the scalp is primarily involved, it is called cradle cap. Seborrhoeic dermatitis of the scalp may be described in lay terms as dandruff due to the dry, flaky character of the skin. However, as dandruff may refer to any dryness or scaling of the scalp, not all dandruff is seborrhoeic dermatitis. Seborrhoeic dermatitis is sometimes inaccurately referred to as seborrhoea.

<span class="mw-page-title-main">Contact dermatitis</span> Human disease

Contact dermatitis is a type of acute or chronic inflammation of the skin caused by exposure to chemical or physical agents. Symptoms of contact dermatitis can include itchy or dry skin, a red rash, bumps, blisters, or swelling. These rashes are not contagious or life-threatening, but can be very uncomfortable.

<span class="mw-page-title-main">Rosacea</span> Skin condition resulting in redness, pimples and swelling, usually on the face

Rosacea is a long-term skin condition that typically affects the face. It results in redness, pimples, swelling, and small and superficial dilated blood vessels. Often, the nose, cheeks, forehead, and chin are most involved. A red, enlarged nose may occur in severe disease, a condition known as rhinophyma.

<span class="mw-page-title-main">Pimecrolimus</span> Chemical compound

Pimecrolimus is an immunomodulating agent of the calcineurin inhibitor class used in the treatment of atopic dermatitis (eczema). It is available as a topical cream, once marketed by Novartis under the trade name Elidel.

Antipruritics, abirritants, or anti-itch drugs, are medications that inhibit the itching often associated with sunburns, allergic reactions, eczema, psoriasis, chickenpox, fungal infections, insect bites and stings like those from mosquitoes, fleas, and mites, and contact dermatitis and urticaria caused by plants such as poison ivy or stinging nettle. It can also be caused by chronic kidney disease and related conditions.

<span class="mw-page-title-main">Nummular dermatitis</span> Medical condition

Nummular dermatitis is one of the many forms of dermatitis. It is characterized by round or oval-shaped itchy lesions. The name comes from the Latin word "nummus," which means "coin."

<span class="mw-page-title-main">Dyshidrosis</span> Human disease

Dyshidrosis is a type of dermatitis that is characterized by itchy blisters on the palms of the hands and bottoms of the feet. Blisters are generally one to two millimeters in size and heal over three weeks. However, they often recur. Redness is not usually present. Repeated attacks may result in fissures and skin thickening.

<span class="mw-page-title-main">Atopic dermatitis</span> Long-term form of skin inflammation

Atopic dermatitis (AD), also known as atopic eczema, is a long-term type of inflammation of the skin (dermatitis). It results in itchy, red, swollen, and cracked skin. Clear fluid may come from the affected areas, which can thicken over time. AD may also simply be called eczema, a term that generally refers to a larger group of skin conditions.

<span class="mw-page-title-main">Erythroderma</span> Inflammatory skin disease with redness and scaling

Erythroderma is an inflammatory skin disease with redness and scaling that affects nearly the entire cutaneous surface. This term applies when 90% or more of the skin is affected.

<span class="mw-page-title-main">Calcipotriol</span> Chemical compound

Calcipotriol, also known as calcipotriene, is a synthetic derivative of calcitriol, a form of vitamin D. It is used in the treatment of psoriasis. It is safe for long-term application in psoriatic skin conditions.

<span class="mw-page-title-main">Perioral dermatitis</span> Medical condition

Perioral dermatitis, also known as periorificial dermatitis, is a common type of skin rash. Symptoms include multiple small (1–2 mm) bumps and blisters sometimes with background redness and scale, localized to the skin around the mouth and nostrils. Less commonly the eyes and genitalia may be involved. It can be persistent or recurring and resembles particularly rosacea and to some extent acne and allergic dermatitis. The term "dermatitis" is a misnomer because this is not an eczematous process.

<span class="mw-page-title-main">Prurigo nodularis</span> Medical condition

Prurigo nodularis (PN), also known as nodular prurigo, is a skin disorder characterized by pruritic (itchy), nodular lesions, which commonly appear on the trunk, arms and legs. Patients often present with multiple excoriated nodules caused by chronic scratching. Although the exact cause of PN is unknown, PN is associated with other dermatologic conditions such as untreated or severe atopic dermatitis and systemic causes of pruritus including liver disease and end stage kidney disease. The goal of treatment in PN is to decrease the itch sensation. PN is also known as Hyde prurigo nodularis, or Picker's nodules.

<span class="mw-page-title-main">Clocortolone</span> Pharmaceutical drug

Clocortolone (Cloderm) is a topical steroid. It is used in the form of an ester, clocortolone pivalate, and applied as a cream. It is used for the treatment of dermatitis and is considered a medium-strength corticosteroid. It is unusual among steroids in that it contains a chlorine atom and a fluorine atom.

<span class="mw-page-title-main">Steroid-induced skin atrophy</span> Medical condition

Steroid-induced skin atrophy is thinning of the skin as a result of prolonged exposure to topical steroids. In people with psoriasis using topical steroids it occurs in up to 5% of people after a year of use.

Topical steroids are the topical forms of corticosteroids. Topical steroids are the most commonly prescribed topical medications for the treatment of rash and eczema. Topical steroids have anti-inflammatory properties and are classified based on their skin vasoconstrictive abilities. There are numerous topical steroid products. All the preparations in each class have the same anti-inflammatory properties but essentially differ in base and price.

Pruritic folliculitis of pregnancy is a skin condition that occurs in one in 3000 people, about 0.2% of cases, who are in their second to third trimester of pregnancy where the hair follicle becomes inflamed or infected, resulting in a pus filled bump. Some dermatologic conditions aside from pruritic folliculitis during pregnancy include "pruritic urticarial papules and plaques of pregnancy, atopic eruption of pregnancy, pemphigoid gestationis, intrahepatic cholestasis of pregnancy, and pustular psoriasis of pregnancy". This pruritic folliculitis of pregnancy differs from typical pruritic folliculitis; in pregnancy, it is characterized by sterile hair follicles becoming inflamed mainly involving the trunk, contrasting how typical pruritic folliculitis is mainly localized on "the upper back, shoulders, and chest." This condition was first observed after some pregnant individuals showed signs of folliculitis that were different than seen before. The inflammation was thought to be caused by hormonal imbalance, infection from bacteria, fungi, viruses or even an ingrown hair. However, there is no known definitive cause as of yet. These bumps usually begin on the belly and then spread to upper regions of the body as well as the thighs.

<span class="mw-page-title-main">Topical glucocorticoids</span>

Topical glucocorticoids are the topical forms of glucocorticoids. Topical glucocorticoids are used in the treatment of many skin conditions. They provide anti-inflammatory, antimitotic, and immune-system suppressing actions through various mechanisms.

References

  1. 1 2 3 4 5 Juhász ML, Curley RA, Rasmussen A, Malakouti M, Silverberg N, Jacob SE (September–October 2017). "Systematic review of the topical steroid addiction and topical steroid withdrawal phenomenon in children diagnosed with atopic dermatitis and treated with topical corticosteroids". Journal of the Dermatology Nurses' Association. 9 (5): 233–240. doi:10.1097/JDN.0000000000000331. S2CID   80154596.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 "Topical corticosteroid withdrawal". DermNet NZ. Retrieved 19 July 2016.
  3. 1 2 3 4 5 6 7 8 Sheary B (June 2016). "Topical corticosteroid addiction and withdrawal - An overview for GPs". Australian Family Physician. 45 (6): 386–388. PMID   27622228.
  4. ↑ Nnoruka EN, Daramola OO, Ike SO (2007). "Misuse and abuse of topical steroids: implications". Expert Review of Dermatology . 2 (1): 31–40. doi:10.1586/17469872.2.1.31 . Retrieved 2014-12-18.
  5. ↑ Rathi SK, D'Souza P (July 2012). "Rational and ethical use of topical corticosteroids based on safety and efficacy". Indian Journal of Dermatology. 57 (4): 251–259. doi: 10.4103/0019-5154.97655 . PMC   3401837 . PMID   22837556.
  6. ↑ Hajar T, Leshem YA, Hanifin JM, Nedorost ST, Lio PA, Paller AS, et al. (March 2015). "A systematic review of topical corticosteroid withdrawal ("steroid addiction") in patients with atopic dermatitis and other dermatoses". Journal of the American Academy of Dermatology. 72 (3): 541–549.e2. doi:10.1016/j.jaad.2014.11.024. PMID   25592622.
  7. ↑ Smith MC, Nedorost S, Tackett B (September 2007). "Facing up to withdrawal from topical steroids". Nursing. 37 (9): 60–61. doi:10.1097/01.NURSE.0000287732.08659.83. PMID   17728660.
  8. 1 2 3 Fukaya M, Sato K, Sato M, Kimata H, Fujisawa S, Dozono H, et al. (2014). "Topical steroid addiction in atopic dermatitis". Drug, Healthcare and Patient Safety. 6: 131–138. doi: 10.2147/dhps.s69201 . PMC   4207549 . PMID   25378953.
  9. ↑ Kling C, Obadiah J (2005-03-01). "Corticosteroid-dependent scrotum". Journal of the American Academy of Dermatology. 52 (3): P47. doi: 10.1016/j.jaad.2004.10.202 . ISSN   0190-9622.
  10. ↑ "Topical steroid addiction: Calls for more support for patients". BBC News. March 2021.
  11. 1 2 Ghosh A, Sengupta S, Coondoo A, Jana AK (September 2014). "Topical corticosteroid addiction and phobia". Indian Journal of Dermatology. 59 (5): 465–468. doi: 10.4103/0019-5154.139876 . PMC   4171914 . PMID   25284851.
  12. ↑ Cirillo N, Prime SS (June 2011). "Keratinocytes synthesize and activate cortisol". Journal of Cellular Biochemistry. 112 (6): 1499–1505. doi:10.1002/jcb.23081. PMID   21344493. S2CID   22289437.
  13. ↑ Lio PA (August 2019). "Topical Steroid Withdrawal in Atopic Dermatitis". Practical Dermatology.
  14. ↑ Ballard, A. (2021, March 22). TSW: What the eczema community needs to know. National Eczema Association. https://nationaleczema.org/blog/tsw-need-to-know/
  15. ↑ Hwang J (25 Dec 2020). "Topical corticosteroid withdrawal ('steroid addiction'): an update of a systematic review". Journal of Dermatological Treatment. 33 (3): 1293–1298. doi:10.1080/09546634.2021.1882659. PMID   33499686. S2CID   231764481.
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