• Topical Steroid Addiction
• Steroid Addiction
• Corticosteroid Addiction
• Steroid Addiction Syndrome
• Topical Corticosteroid Addiction
• Topical Corticosteroid Withdrawal
• Topical Corticosteroid Withdrawal Syndrome
• Steroid-induced Rosacea-like Eruption

• Topical Steroid Damaged Facies
• Red Burning Skin Syndrome
• Steroid Dermatitis
• Steroid-Induced Dermatitis
• Steroid Dermatitis Resembling Rosacea
• Steroid- Induced Rosacea-like Dermatitis
• Topical Corticosteroid-Induced Rosacea-like Dermatitis (TCIRD)
• Red Skin Syndrome

Journal of the American Academy of Dermatology, March 2015:

“In the erythematoedematous variant, the most commonly reported signs were erythema, scaling, papules, nodules, desquamation/peeling, and swelling/ edema. The most commonly reported symptoms were burning/stinging (94.6%), pruritus, pain, and diminished tolerance for emollients. The papulopustular variant may be distinguished from the erythematoedematous variant by the prominent features of pustules, papules, nodules, and less frequently edema and burning/stinging.” (1)

Clinics in Dermatology, May-June 2003:

“All of these patients had been treated with long-term topical corticosteroids, usually with escalating dosage and frequency of application.  In the majority of patients, the initial symptom of pruritus commonly evolved into a characteristic, severe burning sensation. In many cases, systemic corticosteroids had also been administered to relieve the severe erythema and burning, but this only exacerbated the condition. . . .

The pattern of corticosteroid withdrawal was usually quite characteristic. Seven to 10 days after corticosteroids were stopped, an initial flare of erythema occurred at the site of the original dermatitis, accompanied by local spread and marked burning. This flare lasted anywhere from 7 to 14 days and culminated with exfoliation.. . .

Withdrawal symptoms, manifested by angry erythema and burning, were long-lasting and severe.” (3)

Drug, Healthcare and Patient Safety, October 2014:

“TSA [Topical Steroid Addiction] is the situation where skin develops more severe or diverse skin manifestations after the withdrawal from TCS than at preapplication. . . . Before withdrawal, the addicted skin usually looks almost normal or well-controlled by TCS. Patients often subjectively notice . . . the itching may be more uncomfortable than before . . . or the TCS do not work as well as before. . . .

After TCS withdrawal, the erythema often develops from the area of the skin where the intractable eczema remained and spreads gradually day by day. . . . This rebound eruption extends to areas of the skin where TCS have never been applied. The typical spreading course of the rebound eruption extends from the face to the neck, upper extremities, trunk, and then to the lower extremities, although there may be many variants. Sometimes, the rebound eruption spreads from only one eczematous finger to the arms, trunk, face, and lower extremities and then on to the whole body, even when there had been no other eczema on the patient and TCS had been used only on the affected finger. . . .

After the acute phase of the red exudative rebound, a dry, itchy phase follows, with thickened and desquamative skin.”(2)

Cutis, April 2009:

“Children often present with the classic perioral type as well as perinasal and periocular eruptions. . . .”

“Although it was believed that only high-potency topical steroids could produce SIRD [Steroid-induced Rosacea-like Dermatitis], it is important to note that topical hydrocortisone  1% also can cause such an eruption after prolonged use.” (11)

International Journal of Dermatology, January 1979:

“[Topical corticosteroid] Treatment continues optimistically for some weeks or months. Then, deliberately or accidentally (went on vacation without drug, forgot to refill) the skin receives no drug. Promptly, within a day or two, the treated areas become reddened, tender, itchy, cracked, scaling, and erupting into pustules, especially on the face. The original disease may exacerbate, but the key event is the rebound dermatitis which is exceedingly uncomfortable and distressing. The patient rushes to reapply the steroid and secures immediate relief. The itching, dryness, and scaling quickly abate. All is well until the next lapse when rebound dermatitis returns with greater intensity than before. The patient becomes “hooked” in order to prevent the misery producing rebound flare. . . .  At this stage, stopping the steroids leads to a ferocious rebound within one or two days with fissuring, exudation, pustulation (of the face) and always with intolerable discomfort. The patient is now solidly addicted and cannot escape unless fortune furnishes a physician who recognizes the situation and specifies the one treatment the patient fears — withdrawal from the steroid (or starts the weaning process by substituting a weaker steroid).” (4)

Medical Hypotheses, May-June 2005:

“The therapy by corticosteroids influences the production of IgE, that is one of the key markers of the atopic diseases. Thus, therapy of patients with atopic dermatitis by topical corticosteroids within two weeks resulted in the elevation of spontaneous production of IgE by B-cells in vitro. The experiment has showed that corticosteroids are able to induce IgE production by B-lymphocytes when added to a culture in vitro. A synergy of IL-4 and corticosteroids in induction by B-cells of IgE production plays, probably, some role in the influence of corticosteroids on the course of atopic diseases.” (17)

Drug, Healthcare and Patient Safety, October 2014:

“Although the appearance of the skin lesion of TSA [Topical Steroid Addiction] is generally difficult to distinguish from the original skin disease, the distribution or expansion of the lesion might be a little different. The orthodox distribution of atopic dermatitis involves the neck, knees, or elbows (flexor parts of the body); in TSA, the appearance of a skin lesion is not limited to those sites. The only areas not affected by TSA or the rebound eruption are the palms and soles. . . . However, these can also be partially affected in severe cases.” (2)

Dermatology Times, October 2012:

“When examining the patient, look at the erythematous lesions. They will have a different appearance from classic eczema. Atopic dermatitis typically has excoriated, lichenified lesions in the antecubital and popliteal areas. In contrast, patients with steroid-induced dermatitis have distant pruritic papules, nummular wet lesions and general skin vasodilation.” (5)

Journal of the American Academy of Dermatology, March 2015:                         

“Extrapolating from our review, a clinician should favor TCS withdrawal over a flareup of the underlying atopic dermatitis if the following features are present: (1) burning is the prominent symptom, (2) confluent erythema occurs within days to weeks of TCS discontinuation, and (3) a history of frequent, prolonged TCS use on the face or genital region.” (1)

Journal of the American Medical Association Pediatrics (Formerly Archives of Pediatric and Adolescent Medicine), January 2000:

“We evaluated 106 (46 boys and 60 girls) who developed steroid rosacea. . . . The mean age at onset was 7.04 years (range, 6 months to 13 years). Twenty-nine children [27%] were younger than 3 years.” (14)

Journal of the American Academy of Dermatology, March 2015:

“. . . 69 (7.1%) cases were reported in patients 18 years of age and younger, of which only 0.3% were reported younger than 3 years. Burning and stinging are the most frequently reported symptoms with erythema being the most common sign. Signs and symptoms occur days to weeks after TCS discontinuation. . . . there are no data regarding the prevalence of this condition. It is also unclear whether children are actually less likely to develop this disorder or that cases of TCS withdrawal in the pediatric population are underreported.” (1)

British Journal of Dermatology, November 1972:

“Eleven children have shown similar changes on the facial skin. A bright malar flush was accompanied at times by small superficial papules, pustules and scaling. The clinical picture was variable, sometimes closely resembling rosacea and sometimes peri-oral dermatitis, taking an average of 1 year to clear. . . . Seven of the 11 children had a family history of atopy, and 2 had a family history of rosacea. Potent topical corticosteroids may have played a role in the cause of these children’s rash and, on withdrawal, there was sometimes a pustular exacerbation. . . . at least 8 were known to have been treated with potent topical corticosteroids.” (12)

Pediatrics, July 1979:

“Case reports of steroid rosacea in children are not as abundant . . .  in the American Literature. The purpose of this communication is to describe four children who developed steroid rosacea following the use of topical fluorinated glucocorticosteroids and to alert the pediatric community of this avoidable and at times difficult problem.” (13)

Journal of the American Academy of Dermatology, March 2015:

“It is also unclear whether children are actually less likely to develop this disorder or that cases of TCS withdrawal in the pediatric population are underreported.” (1)

Journal of the American Academy of Dermatology, March 2015:

“Almost all authors recommended discontinuing the use of TCS (95.5%). The papulopustular subgroup was more frequently treated with oral antibiotics whereas the erythematoedematous variant reported the use of antihistamines, ice/cool compresses, and psychological support.  . . . It is unclear if either a tapering off of TCS or immediate discontinuation has any added benefits.” (1)

Practical Dermatology, September 2015:

“For those suffering with topical steroid addiction/withdrawal, we should work to maximize all of our other non-cortisone treatments, from antihistamines to phototherapy and beyond—along with lots and lots of support—to help get through it. Systemic cyclosporine also may be helpful in cases where TSW is present but atopic dermatitis is still raging elsewhere and needing control. Nerve calming preparations such as topical pramoxine, oral gabapentin, and even simple cooling techniques with cool compresses, wet wraps, and even mineral water sprays can work together to offer relief in aggregate for these unfortunate patients.” (7)

Clinics in Dermatology, May-June 2003:

“In addition to discontinuation of all corticosteroids, we instituted a therapeutic regimen of emollients, antihistamines, baths, Burow’s solution, and ice compresses. As flares became progressively less severe, UVA and UVB treatments, one to three times a week, were begun in some patients. In five cases, PUVA was instituted when initial atopic dermatitis had been very widespread. Two patients had tried topical tacrolimus but had stopped because of increased irritation. Two of the patients with chronic actinic dermatitis were given a 2-to-3 month course of oral cyclosporin, 1 to 3 mg/kg/day, which appeared not to alter the course of the withdrawal phase. In no other instance were antimitotics, immunosuppressives, or immunomodulators utilized.”  (3)

International Journal of Dermatology, Jan-Feb 1979:

“Finally, what can be done for addicted patients? This is no enterprise for the short- tempered, impatient physician. Withdrawal is agonizing and the doctor must be enrolled in the battle emotionally, providing strenuous support and unremitting encouragement. Frequent contact, by phone and in person, will be necessary to allay fear and to maintain an optimistic outlook.” . . .

“For stalwart, stoical patients, we have used “cold turkey,” replacing the steroid with lubricating cream, applied liberally q.i.d. . . . For most patients, we follow a weaning protocol, using first 2.5% hydrocortisone for several weeks with a warning that this may not completely prevent a rebound flare. Eventually we drop to 1.0% hydrocortisone and finally we substitute lubricating cream, at which time a minor flare is not unusual.” (4)

Journal of the American Medical Association Pediatrics (Formerly Archives of Pediatric and Adolescent Medicine), January 2000:

“Although it has been recommended to gradually withdraw topical steroids in children for fear of a worsening of the rosacea, we reasoned that to continue treating with the preparation that induced the condition could not be supported. Therefore, in all patients, we recommended an abrupt cessation of topical steroid use and initiating treatment with oral erythromycin stearate at 30 mg/kg per day in 2 daily doses for 4 weeks or topical clindamycin phosphate twice daily for 4 weeks in 6 patients who had a history of erythromycin intolerance or allergy. . . .

“Abrupt discontinuation of topical corticosteroids and institution of oral antibiotics resulted in clearing . . .. This finding does not support the concept that prepubertal children with steroid rosacea need to continue low-strength steroids in a gradual withdrawal strategy. This conclusion is supported by the finding that 54% developed the steroid rosacea while being treated with the lowest-strength (class 7) topical corticosteroids. Even over-the-counter hydrocortisone preparations induced steroid rosacea in susceptible children.” (14)

Cutis, April 2009:

“In children, the treatment of SIRD [Steroid-induced Rosacea-like Dermatitis] is similar to adults and involves cessation of topical steroid use as well as therapy with oral and topical  antibiotics. As tetracyclines are contraindicated in children because of discoloration of teeth, oral erythromycin is the antibiotic of choice.  A dosage of 30 mg/kg daily every 12 hours for  4 weeks has been recommended. There have been no case reports regarding the use of tacrolimus and pimecrolimus in the treatment of children with SIRD.”  (11)

Nursing 2007, September 2007:

“Your patient will need a clear outline of what to expect during the withdrawal period. For example, she needs to know that rebound flares will occur, but that they’ll be temporary. To relieve withdrawal symptoms, tell her she can apply cool compresses or refrigerated emollients such as petroleum jelly (Vaseline) or glycerin and rosewater, which have minimal irritant and sensitization potential. . . . Learn to recognize this condition in patients, then give them your guidance and emotional support as they withdraw from steroids and break the cycle.” (8)

Indian Journal of Dermatology, Venereology and Leprology, 2011:

“Treatment is difficult as there is rebound phenomenon with discontinuation of the topical steroid. Gradual tapering with complete cessation of the topical steroid and addition of oral anti-inflammatory antibiotics and/or topical antibiotics are usually recommended to get a good clinical result.” (6)

Clinical, Cosmetic and Investigational Dermatology, July 2016:

“Since the long-term prognosis in AD patients using TCS is not superior to those not using TCS, and there is evidence that a significant number of AD patients improve without using TCS, managing patients declining TCS should be an acceptable scenario. Moreover, if these patients have topical steroid addiction in addition to AD, their symptoms will not resolve unless they cease using TCS. If physicians decline to manage these patients and they are left without medical supervision, then they would be at greater risk of an adverse outcome due to secondary infections. Hence, we believe that physicians treating AD patients should be open to managing them without the use of TCS, if the patient is competent and makes this choice.” (15)

Dermatology Times, October 2012:

“It can take several months to several years for the erythema and symptoms to subside…”  (5)

Australian Family Physician, June 2016:

“The prolonged withdrawal period (months to years) can take a significant toll on the patient’s mental health. Multiple telephone calls and visits for reassurance have been recommended.” (9)

International Journal of Dermatology, Jan-Feb 1979:

“The first few weeks will be a living hell. The time required for the skin to return to normal depends on the degree of atrophy. Long-term addicts may have damage which cannot be completely reversed, but for the most part great improvement can be anticipated over a period of months. It is not wise to underestimate the time required.”  (4)

Clinics in Dermatology, May-June 2003:

“This pattern of flare and quiescence repeated itself but each time with flares of shorter duration and more prolonged quiescent periods. . . . Edema, burning, and erythema decreased with each episode of flare. . . . The time required for corticosteroid withdrawal mirrored the time over which they had originally been applied, and was often protracted.” (3)

British Journal of Dermatology, November 1972:
“The clinical picture was variable, sometimes closely resembling rosacea and sometimes peri-oral dermatitis, taking an average of 1 year to clear.” (12)

Nursing 2007, September 2007:

“Your patient may need support by telephone follow-up because emotional distress often accompanies withdrawal. Warn her that symptoms may last for many months, proportionate to the time she used the topical steroid.” (8)

Australian Family Physician, June 2016:

“Steroid phobia is a separate issue and is not applicable in these patients: TCS addiction is thought to be the result of TCS misuse (overuse and not underuse of TCS). After complete withdrawal, a patient with TCS addiction can expect normal skin or the original eczema symptoms.” . . .

“By being aware of TCS addiction and withdrawal, practitioners may be better able to help prevent this adverse effect and offer supportive care to patients in TCS withdrawal. It would also be useful for GPs to be able to discuss TCS addiction and withdrawal with patients who seek to clarify information they glean from non-medical sources.” (9)

Drug, Healthcare and Patient Safety, October 2014:

“The undertreatment because of steroid phobia is discussed here. . . . TCS is effective, at least for short-term use, on the condition that the patients are not addicted. Therefore, the excessive warning regarding “undertreatment” may may infringe on the patients’ right to select treatment methods and induce the social prejudice that such patients may not be trying to treat the disease earnestly. . . .

Moreover, when the patient becomes addicted to TCS, the recovery cannot be achieved without “undertreatment”.” (2)

Australian Family Physician, June 2016:

“The incidence and prevalence of TCS addiction and withdrawal are unknown.” (9)

Cutis, April 2009:

“The exact incidence of SIRD [Steroid-induced Rosacea-like dermatitis] is not known . . . . The most common age at presentation is 40 to 50 years; however, it also has been described in infants, children, and elderly patients.”  (11)

Journal of the American Academy of Dermatology, March 2015:

“More data are needed regarding the frequency and duration of use that predisposes to this condition. Further, there are no data regarding the prevalence of this condition. It is also unclear whether children are actually less likely to develop this disorder or that cases of TCS withdrawal in the pediatric population are underreported.” (1)

International Journal of Dermatology, Jan-Feb 1979:

“Steroid addiction is a more subtle and more insidious type of side reaction. It is common but is not high in medical consciousness because it frequently goes unrecognized. Hence, it is underreported and not well characterized. Because it develops in stages, often slowly, both the physician and the patient may fail to incriminate the steroid.” (4)

Drug, Healthcare and Patient Safety, October 2014:

“There are no statistics regarding the prevalence of TSA, but a survey conducted in Japan in 2000 may provide us with some information. In the study, the situations of patients with atopic dermatitis [treated] with TCS were compared, before and after 6 months of treatment. The proportion of poorly controlled disease was 19% in adults . . .  Calculated as 19% − 7% = 12% addicted adult patients, and 7% uncontrolled by other factors (ie, undertreatment).” (2)

Journal of the American Academy of Dermatology, March 2015:

“Clinicians and patients should be aware of this entity and the predisposing factors. Patients should be counseled regarding the risks, including TCS withdrawal, from prolonged daily use of TCS beyond their approved indication. Physicians must avoid inappropriate overprescribing and lax monitoring of refills.” (1)

International Journal of Dermatology, Jan-Feb 1979:

“Addiction to topical steroids is a serious medical problem which reaches tragic proportions in some cases. It is more common than realized, sly and seductive and will be prevented only when the physician becomes as impressed with the steroids capacity to do harm as they are with their remarkable power to suppress, not cure, virtually any inflammatory disease.”. . .

“What can be done to minimize the danger of steroid addiction? Banning steroids would be a final solution, but no reasonable person would propose anything so Draconian. The goal must be to use steroids sensibly and with full awareness of the risks.”  (4)

Journal of the American Medical Association Pediatrics (Formerly Archives of Pediatric and Adolescent Medicine), January 2000:

“It has been presumed that over-the-counter hydrocortisone and prescription 1% hydrocortisone were safe to use in children. This is based on the inability of these preparations to suppress the hypothalamic-pituitary-adrenal axis. From our findings it is evident that low-strength steroids may induce rosacea, at least in susceptible children. The finding that the lowest-strength steroids induce rosacea contradicts the strategy that recommends decreasing the strength of topical steroid during treatment of steroid rosacea. Superpotent topical steroids, such as clobetasol propionate or betamethasone dipropionate (including the combination product Lotrisone), were responsible for the steroid rosacea in only 3% of children.” (14)

Australian Family Physician, June 2016:

“While research is very limited to date, avoiding prolonged use of moderate-to-potent TCS on the face may be prudent as this is a highly significant risk factor for the development of TCS addiction and withdrawal. Avoiding continuous use of TCS for longer than two weeks has been suggested by Fukaya et al, and the US National Eczema Association has advised the following:

‘Do not use TCS continuously for more than two to four weeks – then frequency should be tapered to twice weekly use. Your provider should strive to help create a safe and effective long term treatment plan that does not include daily use of TCS, especially on more sensitive areas.’” (9)

Nursing 2007, September 2007:

“When you perform medication reconciliation, be sure to ask specifically about topical products; many people don’t consider creams to be medications and inadvertently omit them from the medication list. Ask your patient for a complete list of topical medications that she currently uses or has used on the affected areas, including steroids, herbal preparations, and over-the-counter products. It’s a good idea to ask your patient to bring in any medications that she’s used on the affected area for you to inspect because some products contain unlabeled steroids. . . . The best time to prevent steroid rosacea is when topical corticosteroids are first prescribed. Tell your patient not to use steroids on her face for longer than 2 weeks and explain adverse drug effects such as steroid rosacea.” (8)

Practical Dermatology, September 2015:

“With proper guidance, respectful usage, and close monitoring, it seems that the vast majority of patients can use topical steroids briefly when needed, and then be steroid-free with very little risk and great benefit. . . .

Close follow up remains critical: for patients who are unable to sufficiently improve or remain clear, moving to the next rung of the therapeutic ladder is imperative, rather than simply settling for daily use of TCS. . . .

While TSW [Topical Steroid Withdrawal] may be more common than we yet know, it seems to be preventable in at least the majority of cases. This gives hope that with widespread recognition of TSW and cautious use of topical corticosteroids, we can take better care of our patients than ever before and hopefully send TSW back into obscurity.” (7)