Topical Steroid Withdrawal (TSW) and Eczema: what You Need to Know

This condition can develop in the weeks after stopping the use of a topical steroid. It can cause a severe rash, swelling, and other symptoms.

TSW is not well understood. Researchers don’t know what percentage of people develop it or why some people react to topical steroids in this way.

Read on to learn more about TSW and eczema.

What is TSW?

Topical steroid creams are often used to treat eczema and other skin conditions, as they can relieve common symptoms like itching and scaling.

TSW is a rare reaction to stopping the use of topical steroid creams. It can result in a rash that is more severe and painful than the eczema it was originally used to treat. This rash can appear as patches or bumps on the skin.

The majority of reported TSW cases are in people with eczema; however, using topical steroid creams for another skin condition over a long period might also contribute to TSW.

There is some evidence that people who previously used topical steroids to treat eczema are more likely to develop a rash that is painful and burning.

On the other hand, people who used topical steroids for other reasons are more likely to develop a rash that is bumpy and has nodules much like acne.

What are the symptoms of TSW?

TSW can lead to multiple symptoms. Not everyone who experiences TSW will have the same symptoms. Since the condition is so rare, there is no set diagnostic criteria.

Usually, the telltale symptom is inflamed skin that causes a painful or burning sensation and appears after stopping topical steroid use. This rash commonly appears on your arms or legs and is known as a “red sleeve,” but it can occur anywhere on your body.

Other symptoms of TSW include:

• skin weeping (eczema with pus-filled blisters)
• skin flaking or shedding
• skin peeling
• a rash that spreads
• a rash in areas that were not previously affected by eczema
• pus-filled bumps under the skin
• hard bumps under the skin
• swelling
• deep wrinkling of the skin
• skin that is sensitive to temperature
• hair loss
• infection
• insomnia
• nerve pain
• chills
• fatigue
• depression

How is TSW diagnosed?

TSW can be painful and distressing. Unfortunately, this condition is very rare and can be hard to spot. People with eczema might have trouble distinguishing TSW from an eczema flare.

There currently are no tests to diagnose TSW. Instead, a dermatologist will use your symptoms and medical history to diagnose the condition.

You might be diagnosed with TSW if you:

• used topical corticosteroid creams for more than a year
• stopped using topical steroid creams in the past few months
• have a rash that is burning, stinging, or painful
• have a rash in areas where you did not previously have eczema
• have widespread redness and swelling on or your arms or legs

What is the treatment for TSW?

TSW is very rare and there is no standard or agreed-upon treatment. If you’re diagnosed with TSW, your dermatologist will help you develop a plan to treat it. Potential treatment options include:

• Slowly stopping the use of steroid creams. Gradually stopping topical steroid creams can help manage TSW.
• Immediately stopping the use of steroid creams. Some dermatologists recommend immediately stopping the use of steroid creams to manage TSW.
• Taking oral corticosteroids. Taking oral corticosteroids for a few weeks can help your body adjust to stopping topical corticosteroids and reduce symptoms of TSW.
• Using cold compresses. Cold compresses and other skin soothing treatments might also be recommended.
• Taking antibiotics. TSW can cause an increased risk of infection. Antibiotics can help manage this risk.
• Receiving a dupilumab injection. Research from 2018 suggests that an injection of the medication dupilumab can help reduce symptoms of TSW.

What are the risk factors for developing TSW?

Researchers don’t know why some people develop TSW. The condition is rare and more studies need to be done to help dermatologists fully understand it. The main risk factor for TSW is using mid- or high-potency topical steroids for a year or more.

The condition appears to be more common in adult women who have applied topical steroids to their face or genital area.

What is the outlook for people with TSW?

TSW might cause symptoms that last weeks, months, or years. People with the condition will recover at different rates and respond to treatments differently. Since the condition is so rare, there is not an average time estimate for recovery or a known outlook.

The bottom line

Most people who use topical steroids are able to stop them without any side effects. In rare cases, people can develop a condition called topical steroid withdrawal, or TSW.

Since eczema is frequently treated with topical steroids, it’s important for people with eczema to know about this rare condition. TSW causes a burning and painful rash. Some people experience additional symptoms, such as hair loss or depression.

Talk with your dermatologist if you’re concerned about TSW. They can help you adjust to an alternative topical medication or suggest other treatments.

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