TSW eczema? A special request blog about a phenomenon that receives too little attention: Withdrawal symptoms when using hormone ointments, or ‘Topical Steroid Withdrawal’ (TSW), ‘red skin syndrome’ or ‘topical steroid addiction’. An underexposed problem during consultations, but a hot topic on the internet and in the Netherlands.
Hormone ointments are the first choice when treating inflammatory skin conditions such as eczema, psoriasis, lichen planus and many other dermatological skin conditions. Hormone ointments inhibit inflammation in the skin, so that complaints such as itching, scaling and redness disappear. Read more about how to properly lubricate a hormone ointment .
What about withdrawal symptoms also called topical Steroid Withdrawal (TSW)
TSW is a potential clinical side effect that can occur when hormone ointments are used incorrectly or overused and then discontinued. It involves inappropriate, prolonged, and frequent use of moderate to high potency topical corticosteroids. In particular, the thin and sensitive parts of the body, such as the face and genital area, are most often affected.
What do we know about TSW eczema?
In the literature, this phenomenon is poorly defined and extremely little studied. There is no explanation and immunological mechanism behind this phenomenon. Having atopy (predisposition to asthma, hay fever and eczema) is a risk factor. One particular finding is that adult women who blush easily are at additional risk. Some cases have also been reported in children with eczema.
There are two distinct forms of TSW: The erythemato-edematous type (redness and swelling) is most commonly seen in patients with atopic dermatitis, and 80% of patients with atopic dermatitis fall into this category. The complaints arise 48 hours to 14 days after discontinuing a hormone ointment and especially in those where an eczematous condition is the main reason.
The other type is the papulopustular type (bumps and pimples), which is more common in patients using hormone ointments for cosmetic purposes or pigmented conditions. At the end of hormone ointments, TSW patients may already show signs of skin damage such as atrophy with stretch marks and telangiectasia (broken capillaries).
In this group, the complaints arise after 48 hours to 21 days after discontinuing a hormone ointment, and especially in those who used the products for acneiform dermatoses and rosacea
From several studies, women may be more likely to suffer from dermatocorticosteroid addiction, this is for cosmetic reasons to keep the skin ‘calm’.
Psychological dependence on hormone ointments and TSW can co-exist, with a threshold to discontinue despite awareness of its harmful consequences.
How do you recognize TSW eczema?
Symptoms that occur with TSW include burning, intense itching and skin scaling, edema, pustules, redness and sensitive skin. However, these symptoms do not belong specifically to TSW.
Suggested criteria for TSW are:
- Long-term use of hormone ointments, months to years. And gradually increasing hormone ointment strengths to achieve remission or reduction of skin complaints.
2. Diagnostic: this involves atopy (atopic eczema), use of strong hormone ointments in the face, oral prednisone use for skin complaints, itching, redness, burning, hypersensitive skin when using cosmetic products, flakes, (oozing) moisture from the skin, edema (swelling) of the eyelids and/or ankles, elephant skin (thickened skin, reduced skin elasticity) and red sleeve (red sleeve- sharply defined redness of the forearms or lower legs).
3. Additional signs of TSW: sleep disturbance, mood disturbance, skin pain, papules, pustules and head light signs (red face except the nose and around the mouth)
The extent to which these complaints occur: Burning 65%, excessive skin scaling 75%; swelling 65%, sensitive skin 47%, diffuse redness skin 100%, elephant skin 56%; red sleeve 40% and headlight sign, 29%.
Doing an Allergy test to demonstrate allergy to hormone ointments or side substances in hormone ointments is difficult because the skin is too stimulated. Consequently, the test result is unreliable and a hormone ointment or wool fat allergy is incorrectly issued.
The key question: how do you get rid of this?
One possibility is to reduce the hormone ointment and switch to a lighter hormone ointment strength. An example of tapering off is lubricating 3-4 times a week or every other day with a lower hormone ointment strength. More on: How to properly lubricate a hormone ointment.
If the eczema complaints are still too intense, a calcineurin inhibitor (such as Protopic or Elidel) ointment is an option. Elidel cream can be used from 2 years old, Protopic 0.03% and 0.1% ointment for teenagers and adults respectively. These are available only by doctor’s prescription. Try it on a small area of skin first, in some it may cause burning. The burning sensation diminishes after a few minutes to even an hour and after several days of consecutive smearing it disappears.
For people with psoriasis, Calcipotriol (Silkis) ointment, contains vitamin D is an option. New on the horizon is Tapinarof 1% cream, a hormone-free cream suitable for mild to severe psoriasis. Based on 1× daily lubrication, for 12 weeks the severity of psoriasis decreased. Keep an eye out…
In the papulopustular type, antibiotic therapy (minocin, doxycycline, erythromycin) is the most commonly mentioned treatment.
Anti-histamic (anti-hay fever pills) is useful for itching symptoms. But cool packs, aloe vera and Avena Sativa (wheat extracts), Vaseline kerosene also help against it. A cream with menthol or perfume is not good in this case, because you can sensitize the skin and provoke eczema. For burning pain, you can use pain medication.
And complete healing has been described and the duration ranges from weeks to years. A survey of 3840 participants with self-reported TSW found that 26% of those who discontinued ointments for more than 5 years reported persistent symptoms. A study assessing blogs of children with reported TSW. The study reported that even 20 months later, 7 of 13 subjects still had “active TSW symptoms such as scaling, erythema, pain, and itching” after discontinuing hormone ointments.
Skin peeling often occurs in people with TSW. In that case you can moisturize the skin frequently and preferably with a cream, ointment or Vaseline. A gel or lotion can dry out the skin even more. Read more about lotions, creams and ointments. An ideal basic care product consists of 2 or 3 (see photo below) of these groups. This supports your skin in various ways to keep it in good condition. Iconic Elements Natural Moisturizer Cream is unscented and contains all three elements (occlusive, humectant and emollients).
Hajar T, Leshem YA, Hanifin JM, Nedorost ST, Lio PA, Paller AS, Block J, Simpson EL; (the National Eczema Association Task Force). A systematic review of topical corticosteroid withdrawal (“steroid addiction”) in patients with atopic dermatitis and other dermatoses. J Am Acad Dermatol. 2015 Mar;72(3):541-549.e2.
Manchanda K, Mohanty S, Rohatgi PC. Misuse of Topical Corticosteroids over Face: A Clinical Study. Indian Dermatol Online J. 2017 May-Jun;8(3):186-191.
Do you have sensitive skin, is it restless or dry? Choose your suitable moisturizer squad to restore your skin in a natural way.
While you are here
Sometimes your skin is irritated and you want to know if it could possibly be from your own skin care products. One reliable trick is the ROAT test. It stands for Repeated open Application Test (ROAT), it is used to investigate whether you have an allergy to a certain (skin care) product. The advantage of the ROAT is that you can easily perform it at home, without having to visit a dermatologist. However, if a skin reaction develops, ALWAYS have it evaluated by your dermatologist. Read more about ROAT