Topical Steroid Withdrawal (TSW), A Comprehensive Treatment Guide. [2023]
Learn about TSW, its causes, symptoms, stages, and effective methods to tackle it.
Key Takeaways
Topical steroids are an important therapy that is often used to treat a variety of conditions including Eczema, Psoriasis and other skin conditions. However, the long-term use of moderate-strong steroids on sensitive areas like the face and neck can cause a condition called TSW (Topical Steroid Withdrawal). TSW is a relatively new phenomenon, and we’re only beginning to fully understand it. In this blog post, we will cover everything you need to know about TSW, including its tell-tale signs, how to avoid it, and ways to ease its symptoms.
What is TSW?
TSW is a skin condition that occurs as a reaction to the withdrawal of steroids after long-term use. It can happen after using steroids for a lengthy period or a strong dose, then suddenly stopping. The condition is thought to be caused by the long-term use of moderate-potent steroids on sensitive areas like the face and neck. The research shows that most individuals with TSW were using mid to high-potency (strength) steroids and used them daily for an extended time, often more than 12 months.
Typical symptoms of TSW include
Sudden redness, especially on the cheeks, with the nose remaining clear
Small bumps that are pus-filled or raised patches of changed skin colour
Massive skin shedding and flaking with swelling
Random burning/stinging pain that is made worse by sunlight and heat.
These symptoms often appear a few days to weeks after steroids are stopped. It is essential to note that TSW affects sensitive areas such as the face/neck and armpits/groins only. The areas of redness often spread to new places that had never bothered sufferers, and there is usually a shift between itching to burning and stinging. The skin may change from ‘rashy’ to more flushed, like a sunburn.
What's Happening Under The Surface?
While scientists are still trying to fully understand why TSW happens, they believe it's due to a combination of several factors.
Skin Barrier Disruption: Our skin acts as a protective barrier, keeping out harmful substances and retaining moisture. Extended use of steroids can weaken this barrier, making the skin vulnerable and sensitive. When you stop using the steroid cream, your skin tries to repair itself, leading to symptoms like redness, peeling, and swelling.
Changes in Immune Response: Steroids work by suppressing our immune system to reduce inflammation. Long-term use might cause the immune system to "get used to" the presence of the steroid. Once the steroid is removed, the immune system can overreact, resulting in an inflammatory response that presents as a rash or other TSW symptoms.
Alterations in the Hypothalamic-Pituitary-Adrenal (HPA) Axis: This is a complex set of interactions between two parts of the brain (the hypothalamus and pituitary gland) and the adrenal glands, which are small glands located above the kidneys. This axis is responsible for controlling our body's response to stress, among other things. Prolonged topical corticosteroid use can suppress this system. Once the TCS is stopped, this axis may over-respond, leading to various symptoms, including those seen in TSW.
In essence, TSW happens because our body gets so used to the presence of the topical steroid that it struggles to adjust when it's no longer there. This adjustment process can trigger a range of symptoms that, although uncomfortable and sometimes severe, are signs that your body is trying to restore its balance.
What are the tell-tale signs of TSW?
TSW presents with a few unique tell-tale signs, including:
Affecting sensitive areas such as the face/neck and armpits/groins only.
Symptoms appear after long-term use of steroids and suddenly stopping the medication.
The areas of redness often spread to new places that had never bothered sufferers.
There’s usually a shift between itching to burning and stinging.
The skin may change from ‘rashy’ to more flushed, like a sunburn.
What are the different stages?
Stage 1: Inflammation: This is the first stage of TSW, and it is characterised by redness, swelling, and itching. The skin may also be oozing or crusting. This stage can last for a few weeks or even months.The inflammation stage is often the most difficult stage of TSW. The itching can be so severe that it can be difficult to sleep or concentrate.
Stage 2: Flaking: This stage is characterised by the skin flaking off. The skin may be very dry and sensitive. This stage can last for a few weeks or even months.The flaking stage is often characterised by the skin flaking off in large sheets. This stage can be uncomfortable, but it is a sign that the skin is healing.
Stage 3: Remodelling: This stage is characterised by the skin rebuilding itself. The skin may be red and bumpy, and it may be very sensitive. This stage can last for a few months or even years. This stage can be frustrating, as the skin may not look its best. However, it is a sign that the skin is healing.
Stage 4: Recovery: This is the final stage of TSW, and it is characterised by the skin returning to normal. This stage can take several months or even years.
It is important to note that not everyone experiences all four stages of TSW. Some people may only experience one or two stages, and the severity of the symptoms can vary from person to person.
How to avoid TSW?
Preventing Topical Steroid Withdrawal (TSW) revolves around using topical corticosteroids (TCS) responsibly, ensuring that their benefits outweigh any potential risks. Here are more detailed tips to help avoid TSW:
Follow the 'Goldilocks Zone': Using the right amount of topical corticosteroids (TCS) is essential for managing symptoms effectively without experiencing unwanted side effects. It's important to find a balance, known as the 'Goldilocks Zone,' where you apply enough days of TCS to control symptoms but avoid overdoing it. This balance can be challenging to find but it's often 7-14 days for the Face and Neck and upto 14 days for the rest of the body. If you need help on how long to use each one, check out our handy guide here.
Use The 'Finger Tip Rule': The Finger-Tip Rule is a simple way to estimate the appropriate amount of TCS to apply. Take a line of cream or ointment from the tip of your finger to the first crease. This amount usually covers an area about the size of two adult hands placed flat. Following this rule helps ensure that you're using enough TCS to treat the affected area effectively. If you're unsure about the right amount to use or have any concerns, it's always a good idea to consult with your healthcare provider.
Always Take Holiday Periods: If you need to use steroids regularly, make sure you're taking plenty of breaks. The length of each break should be as long as you;ve been using them for. E.g. if you've been using steroids for 7 days in a row, make sure you avoid using them for the next 7 days before starting to use them again.
Use the Weakest Strength that Works: There are many different strengths of topical steroids. Always use the least potent one that effectively manages your symptoms.
Monitor for Signs of TSW: Regularly check your skin for signs of TSW, such as redness, burning, stinging, or an unusually severe rash. If you notice these signs, consult with your healthcare professional.
Consider Alternatives: If appropriate, consider non-steroidal alternatives for managing your skin condition, such as moisturisers, Niacinamide, barrier creams, or other topical medications like calcineurin inhibitors.
Supervised Withdrawal: If you've been using topical steroids for a long time, don't stop abruptly. Instead, seek advice from your healthcare professional. They can guide you through a gradual, supervised withdrawal process, which can significantly decrease the risk of TSW.
