Topical steroid withdrawal

This article is about the consequences of topical steroids. For other uses, see Burn and Sunburn.
Topical steroid withdrawal
Other namesTopical steroid rebound phenomena (TSRP), steroid dermatitis, red burning skin syndrome, red skin syndrome, iatrogenic exfoliative dermatitis (idiopathic erythroderma)[1]
Red burning skin syndrome from topical steroids. Face pattern with nose sign and spared palms (soles also spared)
SpecialtyDermatology
SymptomsRed 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 rebound phenomena (TSRP), commonly known as topical steroid withdrawal (TSW), red burning skin syndrome or 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]

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

Before discontinuation, steroid dermatitis is characterised by 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, itchiness, scabs, hot skin, swelling, stinging, hives, or oozing. This is known as topical steroid withdrawal. After the withdrawal period is over, the atopic dermatitis can cease or is less severe than it was before.[8] Topical steroid withdrawal has also been reported in the male scrotum area.[9] Other symptoms include nerve pain, insomnia, excessive sweating, anxiety, 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 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]

A 2025 pilot study by Shobnam et al. (n=16) reported that topical steroid withdrawal is associated with overexpression of mitochondrial complex I, leading to elevated NAD+ and the conversion of tryptophan into kynurenine metabolites; the authors also reported symptom improvement in an open-label series treated with mitochondrial complex I inhibitors.[13] The findings have been the subject of academic correspondence in the United Kingdom. Brown and Burleigh argued in the Journal of Investigative Dermatology that the small sample size and underpowered analyses meant the proposed molecular and cellular mechanisms remained unexplained and warranted further research.[14] In reply, Shobnam et al. agreed that larger studies are needed and that the diagnostic criteria lacked specificity, while maintaining that the work nonetheless provided initial mechanistic insights.[15] A separate letter by Tan, Dawe and Affleck in Clinical and Experimental Dermatology raised concerns that recruitment through topical steroid withdrawal advocacy organisations introduced collider bias.[16] In a 2026 narrative review in Frontiers in Medicine, Myles and Ratley defended the study design while acknowledging that biomarkers obtainable in standard clinical laboratories have not yet been identified and that the proposed mechanisms require validation in larger cohorts.[17]

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] 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 dupilumab (Dupixent). Some physicians have also seen positive outcomes with oral doxycycline or topical clindamycin.[18]

Epidemiology

The prevalence of the condition is unknown.[19] Many cases ranging from mild to severe have been reported in both adults and children. One survey of atopic dermatitis patients treated with topical steroids in Japan estimated that approximately 12% of adult patients may appear to be uncontrolled cases, although they are in fact addicted to a topical steroid.[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.[20]

References

  1. ^ a b c d e 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. ^ a b c d e f g h i j k l m n o p q "Topical corticosteroid withdrawal". DermNet NZ. Retrieved 19 July 2016.
  3. ^ a b c d e f g h 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. ^ a b c 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. ^ a b 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. ^ Shobnam, N; Ratley, G; Saksena, S; et al. (August 2025). "Topical Steroid Withdrawal Is a Targetable Excess of Mitochondrial NAD". Journal of Investigative Dermatology. 145 (8): 1953–1968.e14. doi:10.1016/j.jid.2024.11.026. PMC 12286752. PMID 40088241.
  14. ^ Brown, SJ; Burleigh, A (2025). "Molecular and Cellular Mechanisms Leading to Topical Steroid Withdrawal Syndrome Remain Unexplained and Warrant Further Research". Journal of Investigative Dermatology. 145 (12): 3224–3225. doi:10.1016/j.jid.2025.05.026. PMID 40480485.
  15. ^ Shobnam, N; Ratley, G; Saksena, S; et al. (June 2025). "Reply to Brown and Burleigh's "Molecular and cellular mechanisms leading to topical steroid withdrawal syndrome remain unexplained and warrant further research"". Journal of Investigative Dermatology. 145 (12): 3225–3227. doi:10.1016/j.jid.2025.06.1569. PMC 12258384. PMID 40562352.
  16. ^ Tan, E; Dawe, R; Affleck, AG (November 2025). "Lessons in bias: what topical steroid withdrawal studies get wrong". Clinical and Experimental Dermatology. 50 (11): 2303–2304. doi:10.1093/ced/llaf320. PMID 40696952.
  17. ^ Myles, IA; Ratley, G (2026). "Topical steroid withdrawal: dissecting the controversy". Frontiers in Medicine. 13 1786331. doi:10.3389/fmed.2026.1786331. PMC 13036219. PMID 41924752.
  18. ^ Lio PA (August 2019). "Topical Steroid Withdrawal in Atopic Dermatitis". Practical Dermatology.
  19. ^ Ballard, A. (2021, March 22). TSW: What the eczema community needs to know. National Eczema Association. https://nationaleczema.org/blog/tsw-need-to-know/
  20. ^ 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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