Topical steroid creams long have been a standard treatment for skin rashes caused by infections, insect bites, and a wide array of contact irritants. They are considered relatively safe as prescription items, and some milder versions, hydrocortisone, for example, are available over-the-counter (OTC), without a prescription.
Ironically, instead of relieving redness and irritation, some users are reporting just the opposite, which begins soon after they stop using the topical steroid cream.
First reported in 1979, doctors have come to refer to this odd reaction as Topical Steroid Withdrawal (TSW). It’s known as Red Skin Syndrome (RSS) and steroid dermatitis. It is most often experienced by long-term users of topical steroids after they stop the use. Symptoms include redness of the skin, a burning sensation, and itchiness, which then may be followed by blistering and peeling skin.
RSS seems most common to occur to those who have been regularly applying a topical steroid product at least daily for a year or more. Cases have, however, been reported to occur after as little as two months of use. The list of uncomfortable symptoms do not seem to occur with short term or intermittent use and it is unlikely to happen to those who briefly and irregularly use the non-prescription topical creams.
RSS appears to be a specific adverse effect of long-term steroid use.
Those with atopic dermatitis (eczema) are most at risk because they are the specific population that uses anti-inflammatory steroids the most.
According to the National Eczema Association, a person is more likely to have a skin reaction with use of steroids on the face or genital area. Women seem to experience a greater incidence than men, especially if they blush easily.
Diagnosis of RSS is based on a rash that occurs within weeks of stopping any long term topical steroid. It is difficult to differentiate between RSS and the eczema that originally was being treated potentially causing a missed diagnosis, which can result in the patient using yet another topical steroid treatment. Prescribers and their patients must be aware of the possibility that the red skin syndrome exists and treating it with more topical steroids isn’t the best treatment, similar to pouring gasoline on a fire.
Topical steroid withdrawal occurs in children and can result from discontinuing topical steroids used for as little as two months. The resulting signs and symptoms can last more than 12 months, even with a short duration of use. The specific mechanisms of action are unknown, which makes it difficult to address reliable treatments. Young persons, women, and those with fair complexions seem to be more susceptible, but studies don’t prove it.
A beginning step of treatment involves stopping the use of topical steroids, all of them. They usually can be stopped abruptly, but withdrawing steroid products, topical ones as well as the oral, gradually is a better approach. For RSS, brief use of steroids by mouth can be useful in quickly getting the condition under control. Colloidal oatmeal baths, soothing topical creams, and cold compresses may help, as can oral anti-inflammatory and antihistamine drugs. Failures with these simple approaches could be reason to prescribe more potent medicines, including antibiotics to prevent, or treat, skin infections.
RSS is rare and often misdiagnosed, but it shouldn’t be ignored. The symptoms can be extreme and must be addressed promptly.
Larry Frieders is a pharmacist in Aurora who had a book published, The Undruggist: Book One, A Tale of Modern Apothecary and Wellness. He can be reached at thecompounder.com/ask-larry or www.facebook.com/thecompounder.