Topical Steroid Withdrawal Research Articles

Pediatric Topical Steroid Withdrawal Syndrome: What Is Known, What Is Unknown.

Topical steroid withdrawal syndrome (TSW) is a debated condition marked by burning erythema, severe itching, and dry skin following the discontinuation of topical corticosteroids (TCS). This study reviewed reported pediatric TSW cases. With a total of 21 cases reported (inconsistent data provided), 60% (6/10) used TCS on the face; 69% (9/13) were associated with an escalation in potency of TCS and 75% (3/4) were the erythematoedematous variant. Overall, data on TSW in children is lacking and standardized diagnostic criteria are needed.

Berberine Inhibits the Inflammatory Response Induced by Staphylococcus aureus Isolated from Atopic Eczema Patients via the TNF-α/Inflammation/RAGE Pathways.

Atopic eczema patients exhibit high levels of Staphylococcus aureus (S. aureus) skin colonization. S. aureus can stimulate macrophages and the expression of proinflammatory cytokines. Berberine (BBR), an alkaloid, attenuates S. aureus toxin production. This study investigated if BBR suppressed bacterial growth and inflammatory response induced by eczema-patient-derived S. aureus using murine macrophage (RAW 264.7) and human monocyte cell lines (U937). RAW 264.7 and U937 were treated with BBR at different concentrations and stimulated with heat-killed S. aureus (ATCC #33591) or S. aureus derived from severe eczema patients (EC01-EC10), who were undergoing topical steroid withdrawal, for 24 h. TNF-α protein levels were determined by ELISA, gene expression by qRT-PCR, cell cytotoxicity by trypan blue excursion, and reactive oxygen species (ROS) levels by fluorometric assay. BBR showed a bacteriostatic effect in S. aureus (ATCC strain #33591 and clinical isolates (EC01-EC10) and suppressed TNF-α production in RAW 264.7 and U937 cells exposed to heat-killed S. aureus (ATCC and clinical isolates) dose-dependently without any cell cytotoxicity. BBR (20 µg/mL) suppressed >90% of TNF-α production (p < 0.001), downregulated genes involved in inflammatory pathways, and inhibited S. aureus ROS production in U937 and RAW 264.7 cells (p < 0.01). BBR suppresses S. aureus-induced inflammation via inhibition of TNF-α release, ROS production, and expression of key genes involved in the inflammatory pathway.

53268 Analysis of Google Search Trends on Topical Steroid Withdrawal Syndrome

53268 Analysis of Google Search Trends on Topical Steroid Withdrawal Syndrome

Risk of topical steroid withdrawal reactions

Risk of topical steroid withdrawal reactions

Reviewing the evidence base for Topical Steroid Withdrawal Syndrome in the research literature and social media platforms: An Evidence Gap Map (Preprint)

Reviewing the evidence base for Topical Steroid Withdrawal Syndrome in the research literature and social media platforms: An Evidence Gap Map (Preprint)

Topical steroid withdrawal: a survey of UK dermatologists' attitudes.

The term topical steroid withdrawal (TSW) refers to a condition widely discussed on social media, but rarely mentioned in the medical literature. It typically involves a patient with chronic eczema who abruptly discontinues topical corticosteroids (TCS) believing they are ineffective and damaging. Symptoms include an acute eruption, worse than the previous eczema, of painful erythema followed by oozing, crusting, desquamation and sometimes prolonged systemic weakness. Patients self-diagnose and often avoid healthcare professionals who dismiss the diagnosis and persist in offering TCS, leaving them unsupported. We analysed 121 responses to a survey of UK dermatologists' attitudes to TSW. Views on aetiology included relapsed eczema, erythroderma and a social construct. A total of 88.4% (107/121) agreed that TSW needs better understanding and more research. Respondents earlier in their careers are more cautious than senior respondents about prescribing TCS long term because of TSW, suggesting a trend that might lead to better understanding, communication and management.

Effects of Multi-component TCM Therapy on Skin Microbiome of Infants With Severe Eczema Associated With Topical Steroid Withdrawal.

Effects of Multi-component TCM Therapy on Skin Microbiome of Infants With Severe Eczema Associated With Topical Steroid Withdrawal.

Topical steroid withdrawal and atopic dermatitis

Topical steroid withdrawal and atopic dermatitis

Do people with eczema and their carers understand topical steroid potency? Results of two surveys.

Topical corticosteroids (TCSs) are classified into four potencies: mild, moderate, potent and very potent. Confusion arises from the wide range of products available, none of which have the potency level printed on the tubes or packaging. An online survey of patients and carers of people with eczema showed that only 17% of 984 respondents knew how many potencies there are. In a second survey, 315 respondents provided 1520 assignments of the potency of commonly used TCSs: 55.5% were correct, 21% were underestimates and 23.5% overestimates. Some errors were extreme: 12 (8%) of those using a very potent TCS considered it mild while 9 (27%) using a mild TCS considered it potent or very potent. Other themes expressed in free-text comments included inadequate and conflicting advice about using TCSs and lack of warnings about long-term adverse effects, particularly topical steroid withdrawal. Ninety-five per cent of respondents wanted TCSs to be clearly labelled with potency.

43263 Topical steroid withdrawal: Is YouTube a reliable information source for patients?

43263 Topical steroid withdrawal: Is YouTube a reliable information source for patients?

44453 Identification of Diagnostic Criteria of Topical Steroid Withdrawal Syndrome Using a Modified Delphi Approach

44453 Identification of Diagnostic Criteria of Topical Steroid Withdrawal Syndrome Using a Modified Delphi Approach

P12 #corticophobia: a review of misinformation related to topical steroids

Abstract Misinformation in healthcare is now at crisis level worldwide, with the internet as the primary source of prevarication. Topical corticosteroids (TCS) are a safe and effective treatment used in multiple conditions in paediatric dermatology. Nonadherence to prescribed TCS can be due to phobia secondary to misinformation, and poor compliance is a common obstacle to disease control. TCS phobia is a complex, multifaceted phenomenon that exploits children with skin disease and obstructs their path to successful treatment. This study aims to examine the content of TCS-related misinformation available online. A formal review of PubMed was performed in June 2022, using the terms ‘topical corticosteroids’ AND ‘misinformation’ OR ‘disinformation’ OR ‘conspiracy theory’, along with an informal Google search using combinations of these terms, and further targeted searches on social media applications including Facebook, Twitter, Instagram and TikTok. The main fears expressed by children and parents regarding TCS included potential adverse effects (skin thinning, stunted growth/development). ‘Topical steroid withdrawal’, ‘red skin syndrome’ or ‘TCS addiction’ is a particularly prevalent myth currently being propagated on social media, with most content suggesting that eczema is due to a ‘leaky gut’ and not skin inflammation. Numerous websites promoting misinformation were frequently endorsed by companies advertising ‘natural’ products as treatment alternatives, including ‘herbal’ remedies which can contain significant quantities of corticosteroids or other potent ingredients. The paediatric dermatology community should be vigilant of the type of TCS-related misinformation online, and actively attempt to counteract it with evidence-based advice.

The long-term safety of topical corticosteroids in atopic dermatitis: A systematic review.

Topical corticosteroids (TCS) are a first-line treatment for eczema, but there are concerns about their safety when used long-term. To systematically review adverse effects associated with longer-term use of TCS for eczema. Randomised controlled trials (RCTs), cohort and case-control studies reporting adverse effects of TCS (comparators: no TCS treatment, other topicals) in patients with eczema were identified. Included studies had greater than one year of follow-up, minimum cohort size of 50 participants, or minimum 50 per arm for RCTs. Evidence was GRADE-assessed. Prospero registration CRD42021286413. We found seven studies (two randomised, five observational); two RCTs (n=2570, including 1288 receiving TCS), two cohort (all received TCS n=148) and three case-control studies (cases n=10322, controls n=12201). Evidence from two RCTS (n=2570, children, three and five years' duration) comparing TCS to topical calcineurin inhibitors found intermittent TCS use probably results in little to no difference in risk of growth abnormalities, non-skin infections, impaired vaccine response and lymphoma/non lymphoma malignancies. The five-year RCT reported only one episode of skin atrophy (n=1213 TCS arm; mild/moderate potency), suggesting TCS use probably results in little to no difference in skin thinning when used intermittently to treat flares. No cases of clinical adrenal insufficiency were reported in 75 patients using mild/moderate TCS in the three-year RCT. Small associations between TCS and type-2 diabetes and lymphoma were identified in two case-control studies compared to no TCS, but the evidence is very uncertain. No long-term studies concerning topical steroid withdrawal or eye problems were identified. This review provides some reassuring data on growth and skin thinning when TCS are used intermittently for up to 5years, but many knowledge gaps remain.

PA08 Do parents and carers of children with eczema understand topical steroid potency? Results of a patient survey

Abstract Dermatologists consider topical corticosteroids (TCS) to be the first-line active treatment for most inflammatory skin disorders, including eczema. Well-known adverse effects can usually be avoided by careful prescribing. However, widespread public antipathy to TCS, sometimes amounting to steroid avoidance and phobia, can impair patient care. This fear is largely independent of steroid potency, even though there can be up to a 100-fold difference between the mildest and the most potent products. National Institute for Health and Care Excellence guidelines refer to the World Health Organization’s four-level grading system (mild, moderate, potent and very potent), but information about potency is never found on TCS packaging and rarely in patient information leaflets (Haider Z, Proctor A, Moss C. Potency of topical steroids should be clearly labelled on all packaging. Br J Dermatol 2023; 188:427–8). We surveyed parents and carers to investigate their knowledge and understanding of steroid potency. A SurveyMonkey® questionnaire was promoted by the National Eczema Society on social media, and by Eczema Outreach Support in a newsletter to supporters in January 2023. Of 984 responses received, 25% were from parents or carers of children with eczema. Of these, 97% knew that TCS could have different strengths (potencies), but 44% did not know how many different grades there were, with only 20% correctly answering four. Despite this, 77% of respondents felt ‘somewhat confident’ or ‘very confident’ that they knew how strong their cream was, but of those who were ‘very confident’, 29% did not know how many potency grades there were. Follow-up questions revealed that of those who had used these specific TCS, 93% knew that hydrocortisone is mild, but only 48% correctly identified Fucidin H as mild. Only 54% correctly identified DermovateTM as very potent. When asked ‘Where would you look to find out how strong your steroid creams and ointments are?’ most (69%) answered ‘on the packaging’. Ninety-seven per cent were in favour of clear potency labelling on all steroid creams and ointments. Sixty-two respondents provided free-text comments that were analysed thematically: 51% expressed confusion about TCS or a need for more information; 18% complained that general practitioners were not sufficiently knowledgeable; 20% voiced concerns about TCS, some vehemently, and most citing ‘topical steroid withdrawal’; 11% were positive about TCS and the information provided, two of whom used the ‘Aron regimen’. Several responses indicated confusion between percentage concentration (stated on the tube) and potency. These findings confirm the clinical impressions that parents of children with eczema have limited understanding of potency and need clearer information on the tube and packaging.

PS03 Dermatologist perspectives on topical steroid withdrawal: distrust, disinformation and distance?

Abstract Topical steroid withdrawal (TSW) has become a polarizing phenomenon. The TSW has been described as ‘intense erythema and burning…more prolonged than can be explained by the rebound vasodilation that occurs after discontinuing topical steroids’ (Cotter C, Burton T, Proctor A et al. Topical steroid withdrawal syndrome: time to bridge the gap. Br J Dermatol 2022; 187:780–1). However, TSW acceptance and consensus around diagnosis have proven elusive among dermatologists. This contrasts with a growing patient movement online, with &amp;gt; 572 million views of #topicalsteroidwithdrawal on TikTok. Disparities between patient and clinician acceptance have care implications, relating to psychological wellbeing and engagement with services (Scott S, Deary I, Pelosi AJ. General practitioners’ attitudes to patients with a self diagnosis of myalgic encephalomyelitis. BMJ 1995; 310:508). Self-reported diagnosis of previous emergent, ‘unexplained’ conditions like myalgic encephalomyelitis led to negative clinician attitudes regarding patient concordance, potentially leading to worse outcomes and psychological burden. This study aimed to clarify dermatologist perspectives regarding TSW and assess attitudes toward self-diagnosis. A two-part online questionnaire was developed and disseminated to UK-based dermatology consultants, registrars and fellows via social media and email. Section one presented a TSW clinical scenario and randomized respondents into two groups, one mentioning self-diagnosis of TSW and an otherwise identical control without self-diagnosis. Questions focused on attitudes regarding patient predicted behaviours. Section two asked perspectives on TSW as an entity and management experiences. Comparative data were analysed via SPSS (IBM, Armonk, NY, USA) using statistical tests. In total, 103 responses were received, including those from 51 consultants and 38 registrars. Thirty-four per cent of respondents considered TSW to be a distinct clinical entity, 17.5% did not and 48.5% were unsure. The cohort had seen at least 599 patients presenting with a self-diagnosis of TSW but made the diagnosis itself 157 times. Eighty-two per cent linked the diagnosis to social media and 96.1% most associated TSW with eczema. Eighteen per cent felt their patients with TSW were receiving adequate care. There were statistically significant differences whereby respondents felt patients self-diagnosing with TSW were less likely to comply with treatment (P = 0.003), were more likely to take up one’s time (P = 0.001), would pose difficult management problems (P ≤ 0.001) and would be less desirable on clinic lists compared with controls not mentioning TSW (P ≤ 0.001). Qualitative themes included inappropriate topical steroid use, patient mistrust and desire for further research. Many dermatologists encounter patients presenting with TSW self-diagnoses, but uncertainty regarding its validity is common. Clinicians see this phenomenon as strongly linked to eczema and as being driven by social media. Patients self-diagnosing with TSW were more likely to be viewed negatively in terms of treatment concordance and difficulty with management. A minority of dermatologists believe their patients with TSW are receiving adequate care. Further research is essential to achieve consensus and support patients.

An Analysis of Literature on Topical Steroid Withdrawal in Dermatology

Topical steroids have been used to treat a variety of dermatological conditions and are one of the most commonly prescribed drugs in dermatology. These are Food and Drug Administration (FDA)-approved medications for treating diseases such as eczema, vitiligo, atopic dermatitis, discoid lupus erythematosus, and more. The mechanism of action of topical corticosteroids consists of anti-inflammatory, anti-mitotic, and immunosuppressive effects. Patients on topical corticosteroid treatments must be monitored carefully as there is a potential for adverse effects, especially in treatments lasting longer than several weeks. While when properly prescribed and monitored topical corticosteroid usage is considered safe, there have been growing concerns surrounding topical corticosteroid abuse, phobia, and withdrawal. Current research has focused on new therapeutic strategies and management protocols to improve long-term patient outcomes and mitigate the adverse effects of these drugs. In this narrative review, we describe the recent findings of clinical manifestations, patient perspectives in the literature, current knowledge, and misinformation and abuse pertaining to topical steroids.

Topical Steroid Withdrawal: An Emerging Clinical Problem.

Topical steroid withdrawal (TSW) is a newly described disease characterised by erythema and burning following discontinuation of prolonged use of mid- to high-potency topical corticosteroids. No consensus diagnostic criterion exists. TSW is frequently interpreted as flaring of the underlying disorder or contact allergy to topical treatment. To better characterise TSW symptomatology, detail our experience with management, and assess the proportion of patients who pursue nonconventional management. A retrospective review of case notes collected from our multidisciplinary service between January 2019 and June 2021 was carried out to identify patients presenting with TSW. Nineteen cases of TSW were identified, 15 females and four males. The majority were under 35 years old. Eighteen had atopic dermatitis. The most frequently reported features were redness, skin pain (typically 'burning'), skin sensitivity, excessive skin flaking, insomnia, and severe itching. There was a high burden of anxiety and depression, with three patients expressing suicidal thoughts. Nonconventional treatments were pursued by approximately half the cohort, some of whom sought private consultation with international dermatologists. Improvements were noted in the context of open psychodermatology consultations with an earlier introduction of conventional management options. Many patients report dismissal by dermatology healthcare professionals, often driving them to seek help from unregulated online sources, heightening the burden of mental, social and physical morbidity. Dermatology healthcare professionals need to be aware of TSW, and offer support with shared decision-making when considering treatments.

Investigating Topical Steroid Withdrawal Videos on TikTok: Cross-Sectional Analysis of the Top 100 Videos.

Social media platforms like TikTok are a very popular source of information, especially for skin diseases. Topical steroid withdrawal (TSW) is a condition that is yet to be fully defined and understood. This did not stop the hashtag #topicalsteroidwithdrawal from amassing more than 600 million views on TikTok. It is of utmost importance to assess the quality and content of TikTok videos on TSW to prevent the spread of misinformation. This study aims to assess the quality and content of the top 100 videos dedicated to the topic of TSW on TikTok. This observational study assesses the content and quality of the top 100 videos about TSW on TikTok. A total of 3 independent scoring systems: DISCERN, Journal of the American Medical Association, and Global Quality Scale were used to assess the video quality. The content of the videos was coded by 2 reviewers and analyzed for recurrent themes and topics. This study found that only 10.0% (n=10) of the videos clearly defined what TSW is. Videos were predominantly posted by White, middle-aged, and female creators. Neither cause nor mechanism of the disease were described in the videos. The symptoms suggested itching, peeling, and dryness which resembled the symptoms of atopic dermatitis. The videos fail to mention important information regarding the use of steroids such as the reason it was initially prescribed, the name of the drug, concentration, mechanism of usage, and method of discontinuation. Management techniques varied from hydration methods approved for treatment of atopic dermatitis to treatment options without scientific evidence. Overall, the videos had immense reach with over 200 million views, 45 million likes, 90,000 comments, and 100,000 shares. Video quality was poor with an average DISCERN score of 1.63 (SD 0.56)/5. Video length, total view count, and views/day were all associated with increased quality, indicating that patients were interacting more with higher quality videos. However, videos were created exclusively by personal accounts, highlighting the absence of dermatologists on the platform to discuss this topic. The videos posted on TikTok are of low quality and lack pertinent information. The content is varied and not consistent. Health care professionals, including dermatologists and residents in the field, need to be more active on the topic, to spread proper information and prevent an increase in steroid phobia. Health care professionals are encouraged to ride the wave and produce high-quality videos discussing what is known about TSW to avoid the spread of misinformation.

Topical steroid withdrawal syndrome: time to bridge the gap.

Since their introduction in the 1950s, topical corticosteroids (TCSs) have improved the lives of many dermatology patients. In 2020–2021, over 10·5 million tubes of TCSs were prescribed in England alone1 and in addition, many more were purchased over the counter. Yet in 2021 the Medicines and Healthcare products Regulatory Agency issued a new warning on TCSs, advising patients to seek medical advice if skin burning or redness occurs after discontinuing treatment.2 What has led to this new caution surrounding one of dermatology’s most relied resources? There is growing public awareness and concern about Topical Steroid Withdrawal Syndrome (TSWS), also known as Topical Steroid Addiction or Red Skin Syndrome. A systematic review by Hwang and Lio 3 describes TSWS as a distinct clinical entity of skin burning and erythema, which occurs most frequently in women, sometimes in under 18‐year‐olds, after discontinuation of prolonged application of moderate‐to‐high potency TCSs.3 This review also highlights the poor quality of research that has been completed in TSWS.

Corticosteroid exposure and cumulative effects in patients with eczema: Results from a patient survey

BackgroundIndividuals with eczema may have substantial lifetime corticosteroid exposure, increasing the risk of corticosteroid-related side effects. ObjectiveTo conduct a patient survey evaluating corticosteroid exposure and its cumulative effects in individuals with eczema. MethodsThe multinational online survey was conducted between November 5, 2020, and January 11, 2021. Participants were aged 18 years or older and a patient (n = 1889) or a caregiver of a child (n = 271) diagnosed with having eczema by a medical professional. ResultsAll participants reported using corticosteroids. Average duration of topical corticosteroid (TCS) use was 15.3 years in adults and 3.6 years in children; 75% used TCS 1 to 2 times a day and 50% applied TCS 15 to 30 days/mo. Frequency and duration could not be determined by varying prescription TCS potencies. Oral corticosteroid use was reported by 36% of the participants (23% for eczema), with a lifetime average of 8.4 courses in adults and 8.1 courses in children. Corticosteroids for non-eczema atopic conditions were reported by 49% of the participants. In participants using TCS, 83% of adults and 64% of children experienced worsening symptoms over time. Development of new symptoms and conditions increased with a greater number of corticosteroid treatments and longer duration of TCS use but may have been owing to eczema progression. Symptoms consistent with topical steroid withdrawal syndrome after TCS discontinuation were reported by many participants. ConclusionReported substantial corticosteroid exposure throughout their lifetime eczema experience placed participants at risk of negative outcomes. Corticosteroids are a critical component of eczema treatment for many patients. However, careful corticosteroid prescribing practices and monitoring are needed to avoid side effects. When possible, corticosteroid-sparing strategies should be explored.