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How to Break Free From Topical Steroid Withdrawal (TSW)
By Dr. Diane Angela Fong, ND
As an eczema and topical steroid withdrawal (TSW) survivor and a naturopathic doctor specializing in eczema, I've witnessed firsthand the emergence of TSW as a significant clinical problem. TSW poses a unique challenge for patients who have relied on topical corticosteroids for prolonged periods of time to manage various skin conditions.
Topical corticosteroids are undeniably effective at reducing inflammation and alleviating symptoms associated with dermatological issues such as eczema and psoriasis. However, what many patients don't realize is that prolonged use can inadvertently lead to dependency, making withdrawal upon cessation a daunting reality.
In this comprehensive blog, we'll explore the natural mechanism of steroids, how they mitigate inflammation, the intricate reasons behind topical steroid withdrawal, and the spectrum of symptoms associated with TSW. Additionally, we'll delve into the stages of TSW, its duration, and most importantly, the two-phase Cleanbody approach to healing TSW from the inside out.
Have You Used Topical Corticosteroids?
You might be surprised to learn that you've been using topical corticosteroids without even realizing it. These medications, commonly prescribed for various skin conditions such as eczema, psoriasis, dermatitis, and other inflammatory skin disorders, can go by different brand names and formulations. Let's explore some of the common brand names and forms of topical corticosteroids you might encounter:
Betamethasone (brand names: Diprolene, Diprosone)
Clobetasol (brand names: Temovate, Olux, Cormax)
Hydrocortisone (brand names: Cortizone, Hydrocortisone)
Triamcinolone (brand names: Kenalog, Aristocort)
Mometasone (brand names: Elocon, Elosone)
Fluocinonide (brand names: Lidex, Vanos)
Desonide (brand names: DesOwen, Tridesilon)
Fluticasone (brand names: Cutivate)
Prednicarbate (brand names: Dermatop)
Alclometasone (brand names: Aclovate)
Natural Mechanism of Steroids and Inflammation Reduction
To comprehend how topical corticosteroids work and why they can lead to withdrawal, it's crucial to grasp the natural mechanism of steroids in the body. Corticosteroids, such as cortisol, are naturally produced by the adrenal glands and play a vital role in regulating inflammation, immune responses, and metabolism. When the body encounters stress or inflammation, cortisol is released into the bloodstream, where it binds to glucocorticoid receptors in target cells.
Once bound to these receptors, cortisol modulates gene expression, leading to the suppression of pro-inflammatory genes and the upregulation of anti-inflammatory genes. This results in the inhibition of inflammatory mediators, such as cytokines and prostaglandins, and the attenuation of the inflammatory response. Additionally, cortisol helps regulate immune responses by modulating the function of immune cells, maintaining skin barrier function, and promoting tissue repair.
However, prolonged and excessive use of topical corticosteroids can disrupt the natural processes of cortisol synthesis and action, leading to potential withdrawal symptoms upon discontinuation. Chronic exposure to topical steroids can suppress the hypothalamic-pituitary-adrenal (HPA) axis, leading to decreased production of endogenous corticosteroids by the adrenal glands. This suppression, combined with alterations in skin barrier function and immune responses, can precipitate withdrawal symptoms when topical steroid therapy is abruptly stopped.
Furthermore, topical corticosteroids can suppress the synthesis of cortisol by keratinocytes in the skin. Keratinocytes are responsible for producing cortisol locally in response to stress and inflammation. The suppression of cortisol synthesis in keratinocytes can disrupt the skin's natural ability to regulate inflammation and repair damage, leading to increased susceptibility to skin irritation, infection, and other adverse effects.
Everything You Need to Know About TSW
Understanding the mechanism behind topical steroid withdrawal (TSW) sheds light on the complexities of this condition. But beyond the biological processes involved, it's essential to grasp the broader context of TSW, including its risk factors, causes, symptoms, stages, and diagnosis.
Major Risk Factors for Topical Steroid Withdrawal
Topical steroid withdrawal can affect individuals differently, but certain risk factors increase susceptibility to this condition. These risk factors include:
Topical Corticosteroid Use on the Face (97%): Application of topical steroids to sensitive areas like the face significantly increases the risk of withdrawal symptoms.
History of Atopy (76%): Individuals with a history of atopic conditions such as eczema or asthma are more prone to experiencing topical steroid withdrawal.
Oral Corticosteroid Use (42%): Prior use of oral corticosteroids can sensitize the skin and exacerbate withdrawal symptoms upon discontinuation of topical steroids.
Female Gender (79%): Women are more likely to experience topical steroid withdrawal, possibly due to hormonal factors and differences in skin physiology.
Adults Over the Age of 18 (83%): While TSW can affect individuals of any age, adults over 18 years old are more commonly affected.
Topical Corticosteroid of Medium (69%) or High (21%) Potency: The potency of the topical steroid plays a significant role in determining the risk of withdrawal. Higher potency steroids pose a greater risk.
Topical Corticosteroid Treatment Duration of 6 Months or More (63%): Prolonged use of topical steroids increases the likelihood of developing withdrawal symptoms, especially if used continuously for six months or longer.
Causes of Topical Corticosteroid Withdrawal
The pathogenesis of topical steroid withdrawal involves complex mechanisms that disrupt the body's natural processes. Several factors contribute to the development of withdrawal symptoms, including:
Tachyphylaxis (Reduced Response) with Continued Application: Continued use of topical steroids can lead to a reduced response over time, prompting the need for higher doses to achieve the same effect.
Upregulation of Glucocorticoid Receptor b: Patients with atopic dermatitis may exhibit upregulation of glucocorticoid receptor b, which can contribute to a poor response to topical steroids and subsequent withdrawal symptoms.
Suppression of Self-Cortisol Production: Keratinocytes may experience continued suppression of self-cortisol production even after discontinuation of topical steroids, leading to rebound effects.
Rebound Vasodilation: Topical corticosteroids initially cause vasoconstriction, but upon withdrawal, rebound vasodilation occurs due to increased nitric oxide release, resulting in skin erythema.
Barrier Disruption: Topical corticosteroids can disrupt the skin barrier, leading to a rebound cytokine cascade once the anti-inflammatory effects wear off, exacerbating inflammation and withdrawal symptoms.
Symptoms of Topical Steroid Withdrawal
TSW can manifest with a wide range of symptoms, both physical and cutaneous:
Physical Symptoms:
Burning pain: Individuals may experience a burning sensation in the affected areas, contributing to discomfort and distress.
Severe itch: Itching is a common symptom of TSW and can be intense, leading to scratching and further irritation.
Skin sensitivity: The skin becomes hypersensitive, making it prone to discomfort even from mild stimuli.
Insomnia: Sleep disturbances, including difficulty falling asleep or staying asleep, can occur due to itching and discomfort.
Low mood: TSW can have a psychological impact, leading to feelings of sadness, frustration, or anxiety.
Emollient intolerance: Some individuals may develop intolerance to emollients or moisturizers, experiencing adverse reactions upon application.
Skin Features:
Diffusely red skin: The skin may appear red and inflamed, indicating the inflammatory response triggered by TSW.
‘Elephant wrinkles’: Thickened skin with reduced elasticity, often observed on extensor surfaces such as the elbows and knees.
Red sleeve sign: Erythema of the limbs while sparing the palms and soles, presenting a distinctive pattern of redness.
Headlight sign: Erythema of the face while sparing the nose and perioral skin, resembling the beam of headlights.
Shedding skin (desquamation): Skin shedding or flaking occurs as part of the healing process, revealing new skin layers.
Swelling (oedema): Edema may develop, leading to localized or diffuse swelling in the affected areas.
Serous ooze (exudate): Exudate, a fluid rich in proteins and cells, may be present, indicating inflammation and tissue damage.
Papules +/- nodules: Raised bumps or nodules may develop on the skin, varying in size and distribution.
Pustules: Pustules, filled with pus, can appear as a result of inflammation and secondary infection.
Telangiectasia: Dilated blood vessels may become visible beneath the skin, contributing to the redness and discoloration.
Subtypes of Topical Steroid Withdrawal:
Erythematoedematous subtype: Commonly seen in patients with chronic atopic dermatitis, characterized by a burning sensation, erythema, edema, and scaling.
Papulopustular subtype: Frequently observed after steroid use for pigmentation changes or cosmetic reasons, characterized by papules, pustules, and erythema. This subtype may exhibit fewer symptoms of burning, stinging, or swelling.
Clinical Features in Different Skin Types:
Clinical features may vary depending on the individual's skin type. In darker or more pigmented skin types, changes such as darker or grey skin may be observed instead of redness, highlighting the importance of recognizing diverse presentations of TSW.
Complications of Topical Corticosteroid Withdrawal:
Intense itching and sleep disturbance: Itching can be severe, leading to sleep disturbances and reduced quality of life.
Flare of pre-treatment skin disorder: Pre-existing skin conditions, particularly atopic dermatitis, may worsen during TSW.
Secondary cutaneous infection: Skin breakdown and inflammation increase the risk of secondary bacterial or fungal infections.
Depression/anxiety: Psychological distress, including depression and anxiety, may arise from the prolonged debilitation associated with TSW.
Suicidal ideation: In severe cases, individuals may experience suicidal thoughts or feelings due to the impact of TSW on their mental and emotional well-being.
Use of non-conventional therapies: Some individuals may seek alternative or unconventional therapies in an attempt to alleviate TSW symptoms, highlighting the need for comprehensive management and support.
Steroid phobia: Fear or apprehension toward future steroid treatments may develop as a result of the negative experiences associated with TSW.
Recognizing these symptoms and complications is crucial for early intervention and effective management of TSW. If you suspect you may be experiencing TSW, consult with a healthcare professional for accurate diagnosis and personalized treatment options.
Onset of Withdrawal
The onset of withdrawal from the time of discontinuation ranges from 48 hours to over 3 months. This variability underscores the individualized nature of TSW and highlights the importance of recognizing and managing symptoms promptly.
The Stages of TSW
The healing process of TSW is not linear; it comes in cycles. The body needs time to repair its immune, hormone, and nervous systems. Here are the four stages simplified for ease of understanding:
Stage 1: Inflammation: Characterized by redness, warmth, pain, swelling, and weakness. Blood rushes to affected areas in preparation for healing.
Stage 2: Exudation, Oozing, and Scab Formation: Pus formation occurs, and crusts or scabs form to protect wounds and allow new skin to develop.
Stage 3: Proliferation and Flaking: Skin cells migrate to wounds, proliferate, and flake off as new layers form beneath the surface.
Stage 4: Remodeling: Wounds contract, collagen forms, and the skin returns to normal strength and elasticity.
Identification and Diagnosis
Diagnosing TSW can be challenging due to the lack of consensus on diagnostic criteria. Key features include frequent and prolonged topical steroid use on the affected area, burning or itch, confluent redness within days to weeks of steroid cessation, and associated factors such as a history of atopy or oral prednisone use. Clinical examination and patch testing may aid in diagnosis, although distinguishing TSW from a flare of the underlying skin condition can be difficult.
The Cleanbody Approach to Topical Steroid Withdrawal (TSW)
Healing from Topical Steroid Withdrawal (TSW) is a process that requires both immediate support and long-term strategy. At Cleanbody, we’ve developed a two-phase approach to ensure patients receive the care they need to stabilize their symptoms and address the root causes of their eczema.
Phase 1: Immediate Support for TSW Recovery
The first phase of recovery focuses on stabilizing the body and mind while managing the most urgent symptoms of TSW. This phase typically lasts 1 to 3 months, though the exact duration may vary depending on the severity of symptoms and individual response to treatment. During this time, we address multiple critical areas simultaneously:
Adrenal Support: Prolonged steroid use suppresses the adrenal glands, disrupting the body’s natural cortisol production. To restore balance, we incorporate adrenal-supportive supplements, adaptogenic herbs, key nutrients like vitamin C and B vitamins, and stress-reduction strategies. Supporting the adrenals is essential for regulating inflammation and hormonal balance.
Optimizing Sleep: Sleep is a cornerstone of healing, but TSW often causes severe disruptions due to itching, burning, and skin sensitivity. We recommend natural sleep aids such as magnesium, melatonin (tailored to individual needs), and calming herbal formulas. Sleep hygiene practices like limiting screen time and creating a dark sleep environment are also introduced.
Immediate Symptom Relief: The redness, burning, and pain associated with TSW require immediate attention. We use soothing topical treatments such as natural emollients, probiotic sprays, and hypochlorous acid to reduce inflammation, repair the skin barrier, and prevent infection.
Baseline Nutritional Support: Proper nutrition is critical during this phase to give the body the tools it needs to heal. This includes omega-3 fatty acids for reducing inflammation, zinc for skin repair, probiotics for gut health, and a nutrient-dense, anti-inflammatory diet tailored to each patient’s needs.
Mood Imbalance Support: TSW often comes with significant emotional challenges, including anxiety and depression. Addressing these mood imbalances is vital for overall healing. We incorporate mood-supportive strategies such as adaptogenic herbs and supportive supplements such as magnesium glycinate, GABA, and omega-3 fatty acids, which support brain health and calm the nervous system. Stress-reduction practices, mindfulness techniques, and, when needed, referrals for additional mental health support, are also provided to ensure patients feel emotionally supported throughout their recovery.
By addressing these areas in unison, Phase 1 ensures the body is supported comprehensively and that symptoms are managed effectively. This sets the stage for deeper healing.
Phase 2: Addressing the Root Causes of Eczema
Once the symptoms of TSW have stabilized, and the body and mind have regained balance, we move into Phase 2: uncovering and addressing the root causes of eczema. This phase requires a minimum of 3 months, though many patients continue to work through this phase for longer to achieve lasting results and prevent future flare-ups. At Cleanbody, we often focus on six key areas:
Microbiome Imbalances: Supporting gut health and restoring microbial diversity to reduce systemic inflammation.
Toxic Burden: Helping the body detoxify while reducing exposure to environmental toxins.
Leaky Gut: Repairing the intestinal lining with targeted nutrients to prevent inflammatory molecules from entering the bloodstream.
Leaky Skin: Strengthening the skin barrier with internal and topical strategies to improve its resilience.
Nutritional Factors: Ensuring that patients have optimal levels of essential nutrients, like vitamins, minerals, and fatty acids, while addressing dietary patterns that may contribute to eczema symptoms.
Lifestyle Factors: Encouraging sustainable habits like stress management, proper hydration, and regular sleep to support long-term wellness.
By systematically addressing these root causes, we empower patients to achieve lasting relief and regain control over their skin health. This phase builds on the progress made in Phase 1, ensuring the body is fully equipped to heal from the inside out.
Why the Phased Approach Works
Our phased approach is intentional, recognizing that the body cannot tackle root causes effectively until it is stabilized. Phase 1 provides the immediate support needed to manage the acute challenges of TSW, while Phase 2 focuses on addressing the underlying drivers of eczema. This stepwise strategy prevents overwhelm and creates a sustainable path to recovery.
At Cleanbody, we believe healing is not just about alleviating symptoms but also about empowering patients to reclaim their health through a comprehensive, structured plan. With this two-phase approach, we guide patients toward a healthier, more confident future.
Take the Next Step: Discover Your Root Causes
If you’re struggling with TSW or eczema, understanding your unique root causes is the key to long-term healing. At Cleanbody, we offer the Eczema Root Cause Assessment, which helps identify the factors contributing to your eczema. With this personalized insight, you can take the first step toward regaining control of your skin health.
Take the assessment today to learn more and start your healing journey!
Got Questions?
Dr. Fong is going live to discuss this topic on her weekly Live with the Eczema Doc on Wednesday, December 18, at 12:30 PM PST! Watch the live or check out the replay here:
About the Author:
Dr. Diane Angela Fong, ND, is the CEO and founder of Cleanbody, a wellness company dedicated to treating and preventing chronic disease. She is the creator of the Cleanbody Method, which follows a three-step process: Evaluate (digging into the root causes of chronic disease using lab testing and other evaluation tools), Optimize (enhancing health foundations by addressing nutrition, lifestyle, and toxic exposures), and Support (optimizing organ functions through healing protocols).
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