About Topical Steroid Dependence – Addiction – Withdrawal

Topical corticosteroids are commonly used in the treatment of a wide variety of dermatologic conditions.1,2 Despite effectiveness in the short-term, overuse can lead to a condition known as topical corticosteroid withdrawal (TSW) and addiction, which can have a negative impact on quality of life for these patients.3-6 TSW predominantly affects the face or genital region, however any area of the skin can be involved.4 Females and patients with a history of chronic eczematous conditions (e.g. atopic dermatitis and seborrheic dermatitis) appear to be at risk of developing TSW.4,7-8

TSW is often difficult to distinguish from a flare of the underlying skin condition that prompted the use of topical corticosteroids.8-9 Consequently, topical corticosteroids may continue to be used in these patients in order to avoid an exacerbation of the underlying skin condition.8

It is essential for clinicians and patients to be able to recognize and treat this devastating condition. TSW should be suspected if there is lack of improvement of the underlying dermatologic condition with prolonged use of topical corticosteroids and predominant symptoms of burning along with widespread erythema, scaling, and edema appear within days to weeks after topical corticosteroid cessation.4,6

If clinical suspicion for TSW is high, the recommended intervention is discontinuation of all topical corticosteroid use to restore the skin to its original state prior to treatment.4-6 Moreover, allergic contact dermatitis to topical corticosteroids may present similarly to TSW.7,10 Patch test evaluation can help to delineate an allergic etiology in these patients.  A delayed patch test reading has been recommended to identify a potential delayed-delayed positive reaction to topical corticosteroids.7

References

1.Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014;71(1):116-32.

2.Naldi L, Rebora A. Seborrheic dermatitis. New Engl J Med. 2009;360(4):387-96.

3.Liu ZH, Du XH. Quality of life in patients with facial steroid dermatitis before and after treatment. J Eur Acad Dermatol Venereol. 2008;22(6):663-9.

4.Hajar T, Leshem YA, Hanifin JM, et al. A systematic review of topical corticosteroid withdrawal (“steroid addiction”) in patients with atopic dermatitis and other dermatoses. J Am Acad Dermatol. 2015;72(3):541-9.

5.Fukaya M, Sato K, Sato M, et al. Topical steroid addiction in atopic dermatitis. Drug Healthc Patient Saf. 2014;6:131.

6.Rapaport MJ, Lebwohl M. Corticosteroid addiction and withdrawal in the atopic: the red burning skin syndrome. Clin Dermatol. 2003;21(3):201-14.

7.Gust P, Jacob SE. The role of delayed-delayed corticosteroid contact dermatitis in topical steroid withdrawal. J Am Acad Dermatol. 2016;75(4):e167.

8.Hengge UR, Ruzicka T, Schwartz RA, et al. Adverse effects of topical glucocorticosteroids. J Am Acad Dermatol. 2006;54(1):1-5.

9.Sheary B. Topical corticosteroid addiction and withdrawal in a 6 year old. J Prim Health Care. 2017;9(1):90-3.

10.Gönül M, Gül Ü. Detection of contact hypersensitivity to corticosteroids in allergic contact dermatitis patients who do not respond to topical corticosteroids. Contact dermatitis. 2005;53(2):67-70.