Topical steroid withdrawal (TSW) is an increasingly discussed complication linked to long-term topical corticosteroid use for eczema
We explore one patient’s experience, what the medical profession says, and what skin and aesthetics professionals need to know when supporting clients with compromised skin barriers.
The impact of topical steroid withdrawal and how beauty professionals can help
For many skin professionals, clients presenting with eczema, barrier damage or heightened reactivity are becoming increasingly common. In some cases, concerns around topical steroid withdrawal (TSW) are part of that conversation.
Cosi Care founder Lauren Bell developed mild eczema as a child but says she grew out of it until having a flare-up when she went off to university to study product development.
“I think it was just down to student lifestyle,” she says. “And the regular student stresses like doing a dissertation that triggered it.”
She started using corticosteroid creams and after a couple of years she noticed the small patch she had on her wrist and neck was starting to spread all up her arms and to her chest as well as to her face, particularly around the eyes.
Thinking that more steroid cream was the answer, she upped her usage.
While researching for a solution for the unbearable itching, and as part of her final-year project, she learned about topical steroid withdrawal (TSW) and realised that it could be the cream that was making her eczema worse.
“My brother has eczema too and it’s way more severe than mine, so we decided as a family to stop using it,” says Bell.
The decision led to her skin becoming paper thin, oozing, swollen and painful thanks to intense burning, stinging and itching.
However, stopping topical steroids suddenly is not medically advised – something skin professionals should be mindful of when clients say they plan to “come off” prescriptions.
“Abrupt cessation is not advised. Steroids should be reduced gradually under medical supervision with a clear tapering plan,” says Dr Ahmed El Muntasar, GP and aesthetics doctor.
“If a patient is concerned they may be experiencing topical steroid withdrawal they should seek medical advice from a GP or dermatologist. Self-directed stopping or changing treatment often makes things worse.”
For clinics, this reinforces the importance of referral pathways and clear professional boundaries.
What is topical steroid withdrawal?
“Topical steroid withdrawal (TSW) refers to the symptoms which occur when a patient reduces or ceases use of topical steroids,” explains Westlab Bath Salts founder Penny Hamilton.
“The underlying condition is no longer just the original skin condition, but the body is now also suffering withdrawal symptoms due to becoming reliant on the topical corticosteroids.”
Dr El Muntasar adds, “From a GP perspective topical steroid withdrawal occurs after prolonged use of moderate to potent topical corticosteroids particularly when they are stopped abruptly. Patients may develop burning pain, redness, swelling, sensitivity, dryness flaking and disruption of the skin barrier. It remains a controversial and incompletely understood condition and in the UK, it is still considered a grey area with no clear diagnostic test or formal guidelines.”
Common withdrawal side-effects include burning, swelling, itching, flaking and oozing of the skin, but other symptoms can include nerve pain, altered thermoregulation, atrophy and hair loss.
Withdrawal is often accompanied by painful skin redness, which resembles patches or sleeves of sunburn – hence the term “red skin syndrome” (RSS).
However, “Red skin syndrome is not a formal medical diagnosis,” says Dr El Muntasar. “It loosely refers to erythema which is the medical term for skin redness. Erythema is non-specific and can be caused by many different conditions so while the term may describe what patients see it is not clinically precise.”
For practitioners, this highlights why diagnosis must remain within medical settings – visible redness alone is not enough to determine cause.
Lauren during a TSW flare-up and her fully recovered
What is eczema?
Sometimes referred to as "a worldwide epidemic", atopic dermatitis, or eczema as it’s more commonly known, is a prevalent, complex and persistent inflammatory skin disorder impacted by myriad factors. It often follows a cycle marked by intermittent worsening and periods of remission.
“Derived from the Greek word meaning ‘to boil’, its trademark symptoms include recurring instances of redness, inflammation and pruritus,” explains Cigdem Kemal Yilmaz, founder of CPD-accredited skincare education platform Skin Masterclass.
In the UK up to 20% of school-age children and one in 12 adults suffer from it.
Sufferers often go to their GP for help to relieve the itching and subsequent raw and wounded skin. Topical corticosteroids are commonly prescribed as first-line treatment to manage inflammation.
For skin professionals, understanding eczema as a chronic inflammatory condition, not simply “dry skin”, is key when planning treatments.
The problem with current eczema care
Topical steroids and corticosteroids are medicines applied directly to the skin to treat conditions such as eczema or psoriasis. They block the chemical reactions that cause inflammation and constrict capillaries, reducing swelling and discomfort.
While highly effective when used appropriately, prolonged or unsupervised use can lead to complications in some patients.
Dr El Muntasar stresses balance:
“They are one of the cornerstones of eczema treatment. They reduce inflammation, calm itching, improve comfort and sleep and prevent flares from escalating or becoming infected. They work best when used appropriately and intermittently following a potency ladder starting with mild steroids and stepping up only when needed. If stronger steroids are required, this should trigger review and consideration of other treatments rather than continued escalation.”
For clinics, this underlines why client consultation forms should document current and historic steroid use, potency and duration, particularly before initiating advanced treatments.
Are topical steroids safe?
If used correctly for short periods at a time, topical corticosteroids shouldn’t cause serious side effects, says Hamilton.
Dr El Muntasar adds that risks increase with “Long term continuous use without review using potent steroids on thin or sensitive skin such as the face flexures and genitals poor patient education anxiety driven overuse during flares and lack of specialist input. Lack of clear follow up and monitoring also increases the risk.”
Certain groups may be more vulnerable, including children and those with eczema in sensitive areas.
Importantly, misunderstanding is common.
“Many patients do not fully understand safe use. There is confusion around potency how much to apply when to stop and restart and how long to use treatment. Some patients are overly fearful of steroids while others overuse them. Education around fingertip units potency levels and appropriate treatment cycles is essential.”
For beauty professionals, this means conversations about prescription products should remain neutral, supportive and referral-focused rather than directive.
Dr El Muntasar reassures, “Topical steroids are not dangerous when used correctly. Problems arise when there is misuse, lack of guidance or lack of follow up. Used properly they help millions of people and remain one of the most effective treatments for eczema.”
The impact of TSW
TSW patients can feel unsupported and overwhelmed.
“It can severely affect sleep, mood and confidence,” says Dr El Muntasar. “Patients often experience anxiety, low mood social withdrawal and loss of trust in medical care.”
Bell describes it simply:
“It's hell! Not only are you in 24/7 physical pain but you don't feel like you look good, so you don't want to leave the house and even having a shower is painful.”
Bell says that despite going through the withdrawal badly for a few months, even spending some time in hospital with extreme swelling, she affirms that it was nothing compared to what her brother has gone through.
“He was bed-bound for three months. He didn't leave the house for six months. His skin just wasn’t functioning like skin should.
“He couldn't shower because it would burn, when he walked his skin would crack… he was like a burns victim.
“You can imagine what that does to a young man – unable to date or hang with friends. He was completely crippled by it.”
In clinical settings, professionals may see clients at their most vulnerable – physically and emotionally – reinforcing the need for sensitivity, realistic expectations and clear aftercare guidance.
Bell's brother Rhys during the peak of a TSW flare-up (left) and recovered (right)
What can skin professionals do to help?
Despite the ongoing discussion around TSW, scope of practice remains clear.
“Therapists can support the skin barrier, improve skin quality, recognise red flags and encourage referral but they should not diagnose or treat eczema or topical steroid withdrawal,” says Dr El Muntasar.
Red flags requiring medical referral include “oozing or weeping infection severe pain rapid worsening of symptoms or feeling systemically unwell”.
Treatments to avoid on compromised skin include “strong acids, retinoids, peels, exfoliation and extreme temperatures that can trigger inflammation”.
Instead, professionals can focus on:
- Barrier-supportive skincare
- Fragrance-free, hypoallergenic formulations
- Careful patch testing
- Conservative treatment planning
- Thorough documentation
Hypochlorous acid has shown potential as a non-steroidal alternative for managing certain occurrences of eczema due to its antimicrobial and anti-inflammatory properties, Yilmaz points out.
But, it’s important to note that while it can offer these benefits, it may not fully replace the role of topical steroids in all cases.
“Light therapies (red light particularly is effective for managing eczema), alongside topical products that have hypoallergenic and fragrance-free formulas, with barrier-repairing ingredients such as ceramides, hyaluronic acid, glycerin and colloidal oatmeal, are considered effective,” she adds.
Therapists can also improve adherence and reassurance “by encouraging consistency, setting realistic expectations reinforcing that improvement takes time and helping reduce anxiety,” says Dr El Muntasar.
The need for greater education and clearer guidance
“But, while the MHRA has been in acknowledgement of TSW since 2021, there’s still a lack of evidence-based research or definitive NHS guidelines,” says Hamilton.
Dr El Muntasar agrees that more clarity would benefit both patients and practitioners:
“Yes, education is needed for patients, doctors and healthcare professionals. Reinforcing safe steroid use tapering and long-term management is essential.
“There are gaps around diagnosis tapering strategies and long-term management plans and clearer evidence-based guidance is needed.”
For Bell, raising awareness remains important: “It’s easy to feel very alone with this condition so it’s important to raise awareness to give people hope and help them find solutions for their skin.”
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