Topical glucocorticosteroids (topical GCS, or topical steroids) are anti-inflammatory medications available as creams, ointments, lotions, and solutions. They are widely used in dermatology to treat atopic dermatitis, eczema, and other inflammatory skin conditions and are one of the main treatments for flares of many diseases, including in children.
When used correctly, topical GCS are effective and, in most cases, safe. However, prolonged, frequent, and especially uncontrolled use of medium-, high-, and very-high-potency preparations can lead to adverse effects. One of them is topical steroid withdrawal (TSW).
❓ What is topical steroid withdrawal?
TSW is a collection of symptoms that may occur after stopping or significantly reducing prolonged and frequent use of topical steroids.
The most characteristic manifestations include:
- marked skin redness;
- burning or a sensation of “burning skin”;
- itching.
Later, swelling, pronounced dryness and scaling, oozing, pain, and sometimes small inflammatory lesions resembling pimples may develop.
The inflammation may spread beyond the areas where the medication was originally applied.
TSW is more often described after prolonged use of medium- and high-potency topical GCS, particularly on areas with thin and sensitive skin — the face and genital area.
❓ When can topical steroid withdrawal be suspected?
According to recommendations from the National Eczema Society, topical steroid withdrawal may be suspected if, after reducing the frequency of use or stopping the medication:
- inflammation appears on previously unaffected areas of skin;
- inflammation spreads beyond the area where the medication was applied;
- symptoms become significantly more severe after stopping the steroid;
- the inflammatory process persists for a prolonged period — weeks or months.
However, worsening skin condition after stopping a topical GCS does not always mean TSW. It may be a flare of the underlying condition or another inflammatory skin disease. There is currently no universally accepted diagnostic test or single set of criteria for TSW.
❓ Why does topical steroid withdrawal occur?
TSW is more often associated with stopping prolonged and frequent use of medium- and high-potency topical steroids. It is most commonly described after several months of treatment, although there is no specific duration of treatment after which TSW inevitably develops.
It is thought that the syndrome involves changes in the response of skin cells and small blood vessels to prolonged exposure to steroids. Through their vasoconstrictive and anti-inflammatory effects, these medications suppress redness and inflammation.
After they are stopped, a reverse reaction may occur in predisposed individuals — blood vessels may dilate (redness) and the inflammatory response may increase (itching and burning). Nitric oxide, which promotes blood vessel dilation, may contribute to pronounced redness.
With prolonged use of potent steroids, skin cell renewal may also slow down and the skin may become thinner. The skin barrier becomes more vulnerable, water loss increases, and sensitivity to external irritants may increase, which can further contribute to inflammation after stopping the medication.
Why these changes occur only in some patients is not yet fully understood.
❗️ Be especially careful with facial skin
Facial skin is thinner and more sensitive than the skin on many other parts of the body, so potent topical steroids should not be used on the face for prolonged periods without medical supervision.
In addition to TSW, prolonged uncontrolled use of topical GCS on the face can lead to:
- thinning of the skin;
- visible small blood vessels;
- development or worsening of rosacea;
- perioral dermatitis;
- inflammatory skin eruptions.
Therefore, a medication used to treat dermatitis on the body is not necessarily suitable for prolonged use on the face.
❓ Does this mean that topical steroids are dangerous?
No.
It is important not to create the opposite problem — fear of all “hormonal” creams.
Topical GCS remain important and effective medications for the treatment of inflammatory skin diseases.
The risk of adverse effects depends not only on the medication itself, but also on its potency, amount used, frequency of application, duration of treatment, and the area of skin where it is applied.
A short course of an appropriately selected medication and several months of uncontrolled use of a potent steroid on the face are completely different situations.
❓ What should you do if you have been using a topical steroid for a long time?
Do not abruptly stop the medication on your own or, conversely, continue using it without medical supervision.
If you have been regularly using a topical GCS for a prolonged period, especially on the face, it is important to discuss with a dermatologist:
which medication you are using → how potent it is → how long and how often you have been using it → why symptoms return without the medication → which condition needs to be controlled → how remission can be maintained after changing the treatment.
It is especially important to see a doctor if, after reducing the frequency of use or stopping the medication, you develop marked burning, intense redness, swelling, oozing, or inflammation that begins to spread to previously unaffected areas of skin.
It is important to remember: worsening skin condition after stopping a topical GCS does not always mean topical steroid withdrawal. It may also represent a recurrence or flare of the underlying condition, so the cause of the changes should be determined by a doctor.