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Topical Steroid Withdrawal

John Montgomery9 min read

Topical Steroid Withdrawal

Topical steroid withdrawal (TSW) is a name for a group of skin reactions that some long-term users of Topical Corticosteroids report after stopping them. The skin becomes burning, red (pink, purple or darker on brown and black skin), oozing, then flaking, and the redness can spread beyond where the cream was applied. Patients also call it “red skin syndrome” (RSS) or “topical steroid addiction”. The MHRA calls TSW “the generally accepted patient-led term” and says these reactions “do not necessarily meet the medical pharmacological definition of withdrawal” (Drug Safety Update, May 2024). The 2024 joint statement from the National Eczema Society, British Dermatological Nursing Group and British Association of Dermatologists says clinicians avoid the term RSS, because many conditions turn skin red. They also avoid “addiction”, and the loss of effect that patients describe is closer to tachyphylaxis. Patient groups describe signs such as the “sleeve sign” (palms spared), the “headlight sign” (mid-face spared) and “elephant skin”. The MHRA suggests TSW is more likely when burning rather than itch dominates, the redness is confluent rather than patchy, unusual sites are involved, and there has been continuous use of moderate or high potency steroid. Biopsy does not tell TSW apart from an eczema flare.

Topical Corticosteroids [causes] Topical Steroid Withdrawal MHRA [defines] Topical Steroid Withdrawal Topical Steroid Withdrawal [relates] Atopic Dermatitis

Strength of evidence. The core evidence is thin. Hajar et al. (JAAD 2015) systematically reviewed 34 studies, mostly case reports and series. Reports came almost entirely from the face and genital area (99.3%), mostly in women (81.0%), after long-term inappropriate use of potent TCS. Burning or stinging (65.5%) and erythema (92.3%) were the most common features, and the review described erythematoedematous and papulopustular subtypes. The authors judged TSW “likely a distinct clinical adverse effect of TCS misuse” but graded the evidence as very low quality. Its cause is unknown. The National Eczema Association cites NIH work (Shobnam et al., J Invest Dermatol 2025) proposing excess mitochondrial NAD+. The 2024 UK statement adds rebound vasodilation after the steroid stops narrowing skin blood vessels. Dermatologists themselves are split. In a 2025 UK survey of 103 dermatologists, 34% saw TSW as a distinct clinical entity, 17.5% did not and 48.5% were unsure. In an earlier survey (Barlow et al.), 96% thought most people complaining of TSW had ordinary eczema that relapsed after stopping. The 2024 UK statement lists conditions that can look like TSW: eczema relapse, short-lived rebound redness, steroid-induced rosacea or Perioral Dermatitis, Infected Eczema, contact allergy (including to the steroid itself), Erythroderma, and adrenal suppression.

Topical Steroid Withdrawal [relates] Perioral Dermatitis Topical Steroid Withdrawal [relates] Erythroderma Topical Steroid Withdrawal [relates] HPA Axis Suppression

Conflict: [Patient community / TSW posts, 2020s; anecdotal] present TSW as a common, under-diagnosed injury from any steroid use, and advise stopping all steroids. [NES/BDNG/BAD joint statement, Feb 2024] says TSW “affects only a small proportion of patients seen by dermatologists”, and that many suspected cases are relapse, rebound redness, infection or contact allergy. [MHRA DSU, May 2024] found 267 Yellow Card reports up to Aug 2023, against more than 11 million UK TCS prescriptions a year. It called the reactions “rare” but said frequency “cannot be confirmed” because of under-reporting. Unresolved — add to open_questions.

Children and toddlers. The paediatric evidence base is very small. Ahuja & Lio (Pediatric Dermatology 2025) found only 21 published paediatric cases, aged 8 months to 16 years, 90% of them with Atopic Dermatitis. Every case with data involved at least 3 months of continuous use. 69% had escalated to stronger potencies, and 60% had used TCS on the face. Use patterns ranged from several applications a day to twice-weekly. The authors propose that TSW be a diagnosis of exclusion and call for standard diagnostic criteria. The MHRA’s 2021 review, citing a 2017 nursing-journal review (Juhasz et al.), says that in children TSW “can occur within as little as 2 months of daily use”. The 2024 update instead says reactions follow “long-term (generally 6 months or more)” use of moderate or stronger potency. For a toddler on short courses of mild Hydrocortisone, which is what NICE recommends for the face and nappy area, no published case pattern matches. The risk scenario in toddlers is continuous potent steroid on the face, including steroid hidden in Adulterated Herbal Creams.

Topical Steroid Withdrawal [relates] Weekend Therapy Adulterated Herbal Creams [precedes] Topical Steroid Withdrawal

Conflict: [MHRA DSU, Sept 2021, citing Juhasz 2017] says TSW in children can occur after as little as 2 months of daily use. [Ahuja & Lio, Pediatric Dermatology 2025] found that all paediatric cases with data had at least 3 months of chronic use. [MHRA DSU, May 2024] says “generally 6 months or more”. The minimum exposure that carries risk in young children is unknown. Unresolved — add to open_questions.

Conflict: [Axon et al., BMJ Open 2021; Cochrane, Lax 2022] found no evidence of harm from intermittent or weekend TCS. [Ahuja & Lio, 2025] report paediatric TSW cases with use patterns down to twice-weekly. Unresolved — already logged in topical-corticosteroids conflicts.

Don't self-diagnose TSW and stop a toddler's steroid abruptly

A flare after stopping a steroid is usually the eczema returning. Stopping all treatment can leave a toddler with uncontrolled itch, infection or Erythroderma (more than 90% of the skin inflamed), which needs urgent, often hospital, care. If adrenal suppression is present, stopping suddenly is dangerous (MHRA 2024). Talk to the prescriber first. Also avoid unlabelled “natural” creams sold as steroid-free: they may contain Clobetasol Propionate.

Regulatory and professional statements. The UK has taken the most formal action. After a patient representative raised concerns, the MHRA reviewed TSW in September 2021 (Drug Safety Update vol 15, issue 2, plus a Public Assessment Report). It identified 55 Yellow Card reports and added TSW warnings to every UK TCS product label and leaflet. It told prescribers to use the lowest potency needed, say how long to use it, consider stepping down long-term users, and advise patients not to restart a steroid without advice if the skin worsens within 2 weeks of stopping. In May 2024 it added the four-stage course and potency labels on packs (“mild / moderate / strong / very strong steroid”). The National Eczema Society–BAD position statement (January 2021) was replaced by the February 2024 joint statement with the BDNG. That statement acknowledges TSW and calls for urgent research, but stresses that concerns “should not put people off using topical steroids when they can help”. In the US, the National Eczema Association described TSW in 2022 as “a serious potential side effect of topical steroid use that is not readily recognized by patients and providers”. Its current hub page says the condition is under-researched and warns that mistaking eczema for TSW “could lead to unnecessary under-treatment”. This round found no TSW-specific position statement from the American Academy of Dermatology, and no TSW safety communication from the US FDA. The 2021 regulatory action was the MHRA’s, not the FDA’s.

MHRA [regulates] Topical Steroid Withdrawal National Eczema Society [relates] Topical Steroid Withdrawal British Association of Dermatologists [relates] Topical Steroid Withdrawal National Eczema Association [supports] Topical Steroid Withdrawal

The TSW social-media movement. TSW is largely a patient-led diagnosis that spread online. Mentions of topicalsteroidwithdrawal rose 274% between 2016 and 2020 (Bowe et al., Clin Exp Dermatol 2022), and TSW now has more than 1.1 billion TikTok views (NES/BDNG/BAD 2024). Most posts are recovery diaries. Non-physician “educational” posts score poorly for accuracy and safety and promote cold atmospheric plasma, No Moisture Therapy, red-light therapy and total steroid avoidance. The commonest complaint is feeling dismissed by doctors (Zhu et al., Cureus 2025). The NEA hosts the short film Skin on Fire, which mixes interviews with experts and patients’ stories. The surveys suggest a feedback loop. Patients who self-diagnose TSW mostly learned of it online (82.5%), and clinicians then rate those patients as harder to manage, which deepens their distrust. This is the main channel by which TSW fuels Steroid Phobia in parents and steers them toward Herbal and Home Remedies for Eczema.

Topical Steroid Withdrawal [causes] Steroid Phobia Topical Steroid Withdrawal [relates] No Moisture Therapy Steroid Phobia [causes] Herbal and Home Remedies for Eczema

What parents report

evidence: anecdotal. These are Brave Search snippets of Reddit threads, not a systematic sample.

  • Parents of babies aged 3–5 months on prescribed steroids describe being “soooo scared of tsw”. One writes: “I had to actively avoid any Facebook groups about eczema or steroids because it was ALL about TSW and so scary.” evidence: anecdotal
  • A parent of a 1-year-old with facial eczema reports that desonide works, but “as soon as we get to the 2 week mark and stop, it flares up badly overnight … I’m worried the flare up is tsw”. This pattern is typical of eczema relapse or rebound, as the 2024 UK statement describes. evidence: anecdotal
  • On r/beyondthebump, a commenter tells a parent: “Please stop using steroids; they are very harmful to the skin. She may now be suffering from TSW.” evidence: anecdotal
  • An adult r/eczema member who used steroids as a child says “I have TSW now at 26”. Others in the same threads say rebound flares are common and “TSW is rare. Please use steroids.” evidence: anecdotal

Connections

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