• • AUGUST 18, 2020

  A Systematic Review of Corticosteroid Withdrawal Syndrome 激素戒断综合征

  What is Corticosteroid Withdrawal Syndrome CWS?

  Steroids Withdrawal Syndrome is a distinct clinical adverse effect of steroid. It is also called facial corticosteroid addictive dermatitis, red skin syndrome, topical corticosteroid induced rosacea-like dermatitis, steroid addiction syndrome, steroid dermatitis, post-laser peel erythema, status cosmeticus, red scrotum syndrome, chronic actinic dermatitis, anal atrophoderma, chronic eczema, corticosteroid addiction, light-sensitive seborrheid, perioral dermatitis, rosacea-like dermatitis, steroid- rosacea, and steroid dermatitis resembling rosacea.

  What percent of the patients has steroids withdrawal syndrome?

  Corticosteroid withdrawal syndrome prevalence ranged from 21.0% to 83.7% [1].

  

  What are the symptoms of steroid withdrawal?

  The most common 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 [1-5].

  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… Withdrawal symptoms, manifested by angry erythema and burning, were long-lasting and severe.
  — Marvin J Rapaport and Mark Lebwoh. Corticosteroid addiction and withdrawal in the atopic: the red burning skin syndrome. Clinics in Dermatology. Volume 21, Issue 3, May–June 2003, Pages 201-214

  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.
  —Fukaya M, Sato K, Sato M, Kimata H, Fujisawa S, Dozono H, Yoshizawa J, Minaguchi S. Topical steroid addiction in atopic dermatitis. Drug Healthc Patient Saf. 2014 Oct 14;6:131-8.

  

  How to treat steroid withdrawal?

  Almost all reports recommended discontinuing the use of steroids (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 [1].  It is unclear which benefits patients more, either a tapering off of steroids or immediate discontinuation.

  We report a series of 106 prepubertal children with steroid rosacea. 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.
  — Weston WL, Morelli JG. Steroid Rosacea in Prepubertal Children. Arch Pediatr Adolesc Med. 2000;154(1):62–64.

  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. 
  — Fukaya M, Sato K, Yamada T, Sato M, Fujisawa S, Minaguchi S, Kimata H, Dozono H. A prospective study of atopic dermatitis managed without topical corticosteroids for a 6-month period. Clin Cosmet Investig Dermatol. 2016;9:151-158

  Steroids withdrawal is underreported and underestimated, avoid steroids as a first line therapy. Topical steroids mask some diseases, make some disease worse, and create other diseases. Up to date, method without rebound phenomenon with discontinuation of the topical steroid has not been discovered. By being aware of steroids addiction and avoiding continuous use of steroids, physicians may offer supportive care, eg. herbal medicine to patients in steroids withdrawal.

  How long does topical steroid withdrawal syndrome last?

  Syndrome take many months to several years to resolve. 76.7% of patients with steroid withdrawal syndrome received complete or partial clearance in 3 months, 12.5% in 6 months, 5.5% in 12 months and 5.1% over 12 months respectively after discontinuation use of steroid [1,2]. Time required to recover is proportionate to the time steroids were used.

  The prolonged withdrawal period (months to years) can take a significant toll on the patient’s mental health. 
  — Belinda Sheary. Topical corticosteroid addiction and withdrawal – An overview for GPs. Australian Family Physician. Volume 45, No.6, June 2016 Pages 386-388

  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.
  — Marvin J Rapaport and Mark Lebwoh. Corticosteroid addiction and withdrawal in the atopic: the red burning skin syndrome. Clinics in Dermatology. Volume 21, Issue 3, May–June 2003, Pages 201-214

  Educational Video: 

  Part One : An Overview of TSW

  

  Exploring Corticosteroid addiction and Withdrawl
  from a medical and patients perspecitve. Presented by Dr. Heba Khaled DBS BSc (Hons)

   

  Part Two: Skin On Fire

  

  This documentary increases awareness of Steroid Withdrawal Syndrome  and sheds light on the struggles of patients. Hopefully, it will inspire other doctors to educate themselves about steroid addiction, trust their patients, and offer appropriate medical care.

   

  Postscript

  World War II bomber planes returned from their missions riddled with bullet holes. The first response was, not surprisingly, to add armor to those areas most heavily damaged. However, the statistician Abraham Wald made what seemed like the counterintuitive recommendation to add armor to those parts with no damage. Wald had uniquely understood that the planes that had been shot where no bullet holes were seen were the planes that never made it back. That’s, of course, where the real problem was. Armor was added to the seemingly undamaged places, and losses decreased dramatically. The demage we are not attending to is the deeper nature of the skin diseases — the collapse of multiple coupled complex systems.

  第二次世界大战的轰炸机执行任务返回后，布满了弹孔。毫不奇怪，第一反应是在那些受损最严重的地方增加装甲。但是，统计学家亚伯拉罕·瓦尔德（Abraham Wald）提出了似乎违反直觉的建议，即在没有损坏的飞机部位增加装甲。沃尔德见地独特，没有弹孔的飞机是永远回不来的飞机。当然，这就是真正的问题所在。装甲被添加到看似未损坏的地方，损失急剧减少。对于皮肤病也是如此，也许我们没有注意到的损害是这场疾病更深层次的本质——多重耦合复杂系统的崩溃。

  Reference:

  1. Li AW, Yin ES, Antaya RJ. Topical Corticosteroid Phobia in Atopic Dermatitis: A Systematic Review. JAMA Dermatol. 2017;153(10):1036–1042. doi:10.1001/jamadermatol.2017.2437
  2. Hagar T, Leshem YA, Hannifin JM, etc. (2015) A systematic review of topical corticosteroid withdraw (steroid addiction) in patients with atopic dermatitis and other dermatoses. J Am Acad Dermatol 2015;72:541-549
  3. Belinda Sheary. Topical corticosteroid addiction and withdrawal – An overview for GPs. Australian family Physician. Volume 45, No.6, June 2016 Pages 386-388
  4. Sheary B. Steroid Withdrawal Effects Following Long-term Topical Corticosteroid Use. Dermatitis. 2018;29(4):213‐218. doi:10.1097/DER.0000000000000387
  5. Belinda Sheary. Topical Steroid Withdrawal: A Case Series of 10 Children. Acta Derm Venereol. 2019 May 1;99(6):551-556. doi: 10.2340/00015555-3144.
  6. Marvin J Rapaport and Mark Lebwoh. Corticosteroid addiction and withdrawal in the atopic: the red burning skin syndrome. Clinics in Dermatology. Volume 21, Issue 3, May–June 2003, Pages 201-214
  7. Fukaya M, Sato K, Sato M, Kimata H, Fujisawa S, Dozono H, Yoshizawa J, Minaguchi S. Topical steroid addiction in atopic dermatitis. Drug Healthc Patient Saf. 2014 Oct 14;6:131-8
  8. Weston WL, Morelli JG. Steroid Rosacea in Prepubertal Children. Arch Pediatr Adolesc Med. 2000;154(1):62–64. doi:10-1001/pubs.Pediatr Adolesc Med.-ISSN-1072-4710-154-1-poa9084

  • Skin Matters

By Tony Tang Yuqi

Physician Tony Tang Yuqi leads Tangs Clinical TCM with a wealth of knowledge and experience. Holding esteemed qualifications such as an MSc in Clinical Research from Edinburgh and an MBA from Singapore, alongside a Diploma in Traditional Chinese Medicine and registration as a TCM Physician in Singapore. He believes in a compassionate and holistic approach to healthcare, especially when it comes to TCM treatment for eczema, providing comprehensive patient care.