What is Topical Steroid Withdrawal Syndrome?

Topical Steroid Withdrawal Syndrome (TSW) is a skin disease caused by over-applying potent steroid creams to the skin over an extended period. Steroid creams are usually prescribed to treat persistent eczema but may be prescribed for other skin diseases too.

Steroid creams have their place and appropriate use can help prevent a medical emergency such as a systemic skin infection. However, prolonged or inappropriate use can cause dependence, due to the unbearable withdrawal symptoms.

The symptoms of TSW include severe skin disease, often affecting areas of the skin that never before presented with eczema, and many symptoms related to the skin being unable to perform its normal protective functions. These symptoms may include body temperature dysregulation, skin infections, environmental allergies, food sensitivities due to an overactive immune system, and depression due to both discomfort and the physical appearance of the skin.

How does TSW occur?

Eczema affects up to 25% of children in New Zealand and 7% of adults. Most people with eczema will consult their GP (general practitioner) first and foremost, who will refer them to a Dermatologist only if the case is severe.  Conventional treatment for eczema is usually a topical steroid cream, and maybe a soap-free wash or fatty cream (some of which contain steroids).

When you regularly apply cortisone preparations to the skin the body’s production of the natural anti-inflammatory hormone ‘cortisol’ reduces over time. So that when the patient stops applying the cortisone creams, the inflammation increases and the body’s natural defences are low.

Steroid creams come in varying strengths, but all are intended to be used short-term for acute disease. The doctor or dermatologist will usually start someone on a low strength cream, but if the disease persists the prescription may get more potent over time. Many of the commonly prescribed creams are 50-100 times more potent than the low potency ‘starter’ creams.

How do you prevent it?

At Auckland Skin Clinic we address eczema using natural medicine. We see many patients that have been applying potent steroid creams for several years because they needed some relief and were unaware of other options. Most of these patients will go through some steroid withdrawal symptoms and will have to wean off the steroids and onto our natural ointments.

Historically only a few patients would present with full-blown Topical Steroid Withdrawal Syndrome. But in the past few years we have noticed a marked increase in the incidence of TSW in New Zealand, partly due to the higher incidence of eczema (the gateway condition) and partly due to better public awareness of TSW.

Ultimately prevention of TSW is the best cure. Addressing the underlying cause of the eczema or other chronic skin disease, and using only safe, natural topicals is in our view the best course of action.

How do you treat TSW?

If TSW is established we support patients by using very gentle topical preparations that help to relieve symptoms and improve skin barrier function. We expect higher skin sensitivity in these patients due to the thinning effects of steroids on the skin.

The heroes are the herbal medicines and nutrients we give to help restore adrenal and immune function and normalise the allergic response.

We also utilise testing and the case history to help get to the bottom of what allergies or sensitivities may have caused the skin condition that led to steroid treatment in the first place. This helps to prevent a recurrence and ensure a complete recovery.

It takes at least a year to recover fully from TSW. However, improvements are typically seen within a couple of weeks on our protocols. In addition to natural topical and oral medications we provide dietary and lifestyle advice, so that the results are sustainable as overall health is improved.

Once the skin is healed, histamine levels are back to normal and we’ve established what the root cause is, it’s easy to avoid or manage skin disease flares without using steroid creams. The diet can be more relaxed and the patient knows how to manage allergen exposure.

Is it ever okay to use steroids?

Steroid drugs, oral and topical, certainly have their place for many acute conditions. Asthma inhalers can be life-saving and oral prednisone can really help to mitigate a potential medical emergency.

However, topical corticosteroids are not a long-term solution for chronic skin conditions. People need to be made aware of the risks of prolonged use of topical corticosteroids and discuss this with their doctor if they’re concerned.