Topical steroid withdrawal and steroid phobia: Navigating this diagnostic dilemma

Topical corticosteroids (TCSs) have been in use for decades as a first-line therapy for many chronic inflammatory skin conditions. While many of their potential adverse effects are well known, more recently a phenomenon known as topical steroid withdrawal (TSW) has been increasingly recognized. TSW appears to be a rare condition associated with long-term, inappropriate use of high-potency TCSs, mainly on the face, and is more commonly reported by women than men. The symptoms of TSW, including burning pain, skin redness and edema, overlap with many other skin conditions. This, along with the lack of high-quality evidence and agreed-upon diagnostic criteria, is hindering our understanding of the condition. Proposed mechanisms of action for TSW include “rebound” vasodilation, mediated by nitric oxide, and complex 1-mediated oxidation of NAD+, but evidence is limited. When used appropriately, TCSs can be a safe and effective treatment, but “steroid phobia” is a growing problem, fueled by a vast amount of low-quality, inaccurate information available online. Healthcare providers need to listen to their patients’ concerns, and consider all possible diagnoses, encouraging their patients to consult professional, evidence-based advice. Large, prospective clinical trials are needed so consensus on definition and diagnostic criteria can be defined.