Topical steroid withdrawal

Background

Topical corticosteroid withdrawal (TSW or TCSW) is a rebound reaction associated with the cessation of moderate to high strength topical corticosteroids after a period of prolonged use, affecting roughly 1 in 10 patients using topical corticosteroids. This condition is a relatively recent development in dermatologic literature and consensus opinions for its precise cause, diagnosis, and treatment have not yet been reached. The research into this condition is ongoing and evolving, so current literature should be consulted when diagnosing and treating suspected TSW.

Clinical Features

History

• History of moderate to high strength topical corticosteroid use
• History of topical corticosteroid use 6< months
• History of atopic dermatitis
• Females have a higher risk

Physical Exam

Common Symptoms

• Burning pain
• Severe itch
• Skin sensitivity
• Insomnia
• Low mood
• Emollient intolerance.

Cutaneous Features

• Diffusely red skin
• ‘Elephant wrinkles’: thickened skin with reduced elasticity, usually affecting extensor surfaces
• Red sleeve sign: erythema of limbs, sparing the palms and soles
• Headlight sign: erythema of the face, sparing the nose and perioral skin
• Shedding skin (desquamation)
• Swelling (edema)
• Serous ooze (exudate)
• Papules +/- nodules
• Pustules
• Telangiectasia.

Differential Diagnosis

Other Rash

• Acute generalized exanthematous pustulosis
• Allergic reaction
• Aphthous stomatitis
• Atopic dermatitis
• Coxsackie
• Dermatitis herpetiformis
• Exfoliative erythroderma
• Impetigo
• Pellagra
• Pityriasis rosea
• Serum Sickness
• Tinea capitus
• Tinea corporis

Evaluation

• 

  TSW effects on the face, chest, and arms

• TSW2.jpg

  Red sleeve sign

Diagnosis

No consensus diagnostic criteria have been established for TSW.
Refer to primary clinical features:

• Burning, stinging, or painful skin as compared to the more common symptom of itch associated with eczema
• Confluent or general redness such as a “red sleeve” pattern on the arms or legs, often with significant swelling (versus the “patchiness” often seen with eczema)
• A history of significant, especially escalating, use of medium to high potency topical steroids and/or oral steroids

Management

There is no current consensus for effective treatment modalities in reducing the time for symptoms to resolve.

Common Treatments

• Discontinuation of topical corticosteroids
  • Abrupt cessation vs tapering is debated
• Dupilumab may be considered in atopic dermatitis patients
• Prevention and treatment of any secondary infection
• Phototherapy
• Immunosuppressants

Symptom Management

• Emollients (if tolerated) and moisturizers
• Cold compresses, ice, and gabapentin for burning pain
• Antihistamines for itch
• Psychological support

Disposition

Refer to dermatology for outpatient follow-up and management.

External Links

1. https://dermnetnz.org/topics/topical-corticosteroid-withdrawal
2. https://nationaleczema.org/blog/tsw-need-to-know/