Topical corticosteroid withdrawal is an infrequent rebound reaction that happens in patients who have excessively used topical steroids and occurs following cessation.

This condition is typically a result of long-term application of topical corticosteroids with moderate to high potency. Withdrawal symptoms might manifest as skin burning, itching, redness, scaling, swelling, papules, or pustules.

Etiology:

The etiology of topical steroid withdrawal may be explained by the following mechanisms:

Tachyphylaxis, which is a decrease in response, occurs with continued application, resulting in the need for higher doses.
Patients with atopic dermatitis who do not respond well to topical steroids have an upregulation of glucocorticoid receptor b.
Following the withdrawal of topical steroids, keratinocytes continue to suppress the formation of self-cortisol.
Topical corticosteroids induce vasoconstriction, however, upon discontinuation, there is a rebound effect of vasodilation due to an increase in the release of nitric oxide, resulting in skin redness (erythema).
Disruption of the barrier leads to a subsequent release of cytokines, triggering a cascade of immune responses, after the anti-inflammatory effects of topical corticosteroids are stopped.

Clinical manifestations:

The withdrawal symptoms might begin anytime from 48 hours to more than 3 months after discontinuation.

Withdrawal generally manifests in four distinct stages:

Typically, a few days after stopping the treatment, there is a sudden eruption of intensely red and oozing skin, which may spread to places that were not previously treated.
The skin experiences dryness and itchiness accompanied by shedding, also known as desquamation.
The skin begins to regenerate, although it becomes more sensitive and may experience occasional flare-ups.
The skin returns to the state that it was before topical corticosteroid cessation. The duration of the recovery process can range from several weeks to several years.

Symptoms:

Severe itch
Intense itching
Burning pain
Insomnia
Depressed state
skin hypersensitivity
Intolerance to emollients.

Skin characteristics:

Erythematous skin
Elephant wrinkles refer to the thicker skin with decreased flexibility that typically affects the extensor surfaces of the body.
The red sleeve sign refers to the presence of erythema (redness) on the limbs, but the palms and soles are not affected.
The headlight sign is characterized by redness (erythema) across the face, but specifically excluding the nose and the area around the mouth (perioral skin).
Skin shedding (desquamation)
Edema
Exudate.
Telangiectasia
Papules with or without nodules
Pustules.

Diagnosis:

One of the challenges is determining whether the observed skin reaction is a result of discontinuing topical corticosteroids or a deterioration of the underlying skin condition for which the steroids were given.

The diagnostic criteria for topical corticosteroid withdrawal lack consensus. However, recent literature highlights the following key features:

Frequent and prolonged topical steroid use on the area of initial eruption
Frequent topical steroids use on the face or genital area
Sensation of burning or itching

Often associated with:

Atopy history, particularly atopic dermatitis
History of using oral prednisone to treat skin conditions
sensitivity
Skin shedding
Swelling, particularly in the eyelids or ankles, and the presence of ‘elephant wrinkles’ on the back of the elbows and front of the knees (extensors).
Red sleeve sign.

Patch testing is a valuable tool for ruling out contact dermatitis caused by topical corticosteroids, cream excipients, or other topical treatments such as emollients. However, this can be challenging if there is not enough healthy skin available for testing.

Histology is not a reliable method for diagnosing topical corticosteroid withdrawal because the histological signs it presents, such as epidermal atrophy, spongiosis, and parakeratosis, are not specific enough.

Management:

General measures:

Emollients and moisturizers.
cold compresses, the use of ice, and the administration of gabapentin for burning pain.
Antihistamines are used to alleviate itching.
Pain management with simple analgesic.

Specific measures:

The primary treatment approach is discontinuing the use of topical corticosteroids, while closely monitoring for any rebound reactions.
There is controversy around tapering vs abrupt withdrawal.
Gradually reducing the dosage of oral corticosteroids.
Dupilumab should be taken into consideration for people with atopic dermatitis.
Prevention and treatment of any subsequent infection.
Phototherapy.
Immunosuppressants.

Prevention:

Gradually decrease the frequency and potency of topical corticosteroids once the inflammatory skin conditions have resolved.
Avoid prolonged use of strong topical corticosteroids on the face.
Reduce the length of continuous and prolonged corticosteroid treatment, for example, to less than 2 weeks. Certain disorders, including vulval lichen sclerosus, may require a therapy duration beyond 4 weeks in order to optimize the favorable response.
Decrease the strength and frequency of topical steroid usage from daily to twice weekly after 2-4 weeks of treatment.

Finally, atopic dermatitis and other skin disorders should be well treated despite concerns about the risk of topical corticosteroid withdrawal, since a considerably higher proportion of patients react to effective topical steroid use than have withdrawal symptoms.

Written by:

Mashael Alanazi, Medical student

Revised by:

Maee Barakeh, Medical student

References:

DermNet