Exploring Current and Emerging Approaches to Topical Steroid Withdrawal
Topical Steroid Withdrawal (TSW) is an increasingly recognised iatrogenic condition that arises after prolonged or inappropriate use of topical corticosteroids (TCS). Although not formally included in major dermatological diagnostic manuals, growing clinical and patient-reported evidence has pushed it into the spotlight. People experiencing TSW face a complex array of symptoms including burning, erythema, swelling, skin sensitivity, insomnia, and psychological distress.
As of 2025, there remains no universally accepted or standardised treatment protocol for TSW. Most medical literature describes it as self-limiting, yet the recovery period can last months or even years, and supportive care is often essential. This article outlines the major categories of treatments currently being explored, ranging from symptom management and lifestyle-based interventions to immunomodulatory pharmaceuticals and experimental therapies. It aims to present an up-to-date, empathetic, and scientific overview of what is available today — and where the field may be heading.
Understanding the Nature of TSW
TSW develops following the cessation of topical corticosteroids, particularly after prolonged or high-potency use. Many people experience a rebound phenomenon: once the suppressive effect of the steroids is removed, the skin reacts with intense inflammation. This is compounded by the return of the original skin condition, often atopic dermatitis (eczema).
Because TSW is an iatrogenic reaction, it is biologically and clinically distinct from eczema, though the two frequently overlap. This distinction is crucial because treatments that help eczema do not always help TSW, and vice versa. Any approach to treatment must account for the sensitivity of TSW-affected skin, the heightened immune reactivity, and the systemic impact withdrawal can have on mental and physical health.
Supportive Care and Symptom Management
The mainstay of TSW care in 2025 continues to be supportive management — interventions aimed at easing symptoms while the body recovers naturally. These do not treat the root cause but can reduce suffering and help maintain quality of life.
Cold therapy
Many patients report that cold compresses, ice packs, or cool water immersion can relieve burning sensations and reduce inflammation temporarily. While this does not accelerate healing, it provides critical comfort during flare-ups.
Bath therapies
Dead Sea salt or magnesium salt baths are frequently used by people with TSW. Anecdotal evidence suggests they can soothe the skin barrier and reduce itching, though high-quality clinical trials are lacking.
Sleep and mental health support
Insomnia, anxiety, and depression are common in TSW. Cognitive behavioural therapy (CBT), mindfulness-based stress reduction (MBSR), and short-term use of sedating antihistamines or melatonin (under medical guidance) are often used to improve sleep and reduce psychological strain. Psychological support is considered a cornerstone of comprehensive care.
Barrier support
Some people tolerate bland emollients or natural oils, while others find that any topical product worsens their symptoms. This has given rise to the controversial No Moisture Treatment (NMT), which involves avoiding all moisturisers and bathing minimally to encourage natural barrier function. Evidence for NMT remains anecdotal, and dermatologists are divided on its safety and efficacy.
Nutritional and Lifestyle Interventions
Because TSW can trigger systemic inflammation and immune dysregulation, many patients experiment with dietary and lifestyle changes. While these are not proven cures, they can support general health and may reduce eczema activity, which can indirectly aid recovery.
Anti-inflammatory diets
Some evidence suggests that reducing processed sugar, dairy, and gluten while increasing omega-3 fatty acids (e.g. fish, flaxseed), fermented foods, and antioxidant-rich vegetables may benefit skin health. Clinical trials on diet specifically for TSW are lacking, but diet is widely discussed in patient communities.
Gut-skin axis support
Emerging research links gut microbiome dysbiosis to inflammatory skin diseases. Probiotics and prebiotic-rich foods are used by some people to support gut balance, although robust evidence in the context of TSW is not yet available.
Stress management
Stress can worsen both eczema and TSW symptoms. Practices such as yoga, meditation, and gentle physical activity are often incorporated to help modulate the neuroimmune system during recovery.
Traditional and Complementary Medicine
Traditional Chinese Medicine (TCM)
TCM views TSW-like presentations as an internal imbalance. Herbal formulas (such as those containing Scutellaria baicalensis, licorice root, or rehmannia) and acupuncture are sometimes used to relieve itching, promote detoxification, and calm inflammation. Several small-scale studies in eczema suggest potential benefits, but clinical evidence for TSW is still sparse. Care must be taken as TSW skin can be extremely reactive.
Naturopathy
Some naturopaths incorporate dietary changes, herbal supplements, and detoxification protocols. Common supplements used include evening primrose oil, vitamin D, and zinc. These approaches are largely based on theoretical mechanisms and patient experience, and should be used with caution under professional guidance.
While these approaches are not universally accepted in conventional dermatology, many patients report symptomatic relief and a sense of empowerment from using them — highlighting the importance of personalised care and shared decision-making.
Pharmaceutical and Immunomodulatory Treatments
Despite resistance to pharmaceuticals in much of the TSW community, some people with severe, protracted TSW consider systemic medications under specialist supervision. These are typically reserved for cases where inflammation is extreme or unmanageable.
Dupilumab (Dupixent)
Originally developed for moderate-to-severe atopic dermatitis, dupilumab blocks the IL-4 and IL-13 pathways involved in type 2 inflammation. While not approved specifically for TSW, some case reports describe improvement in TSW-like symptoms with its use. Results are inconsistent, and more research is needed to clarify its role.
Cyclosporine and methotrexate
These systemic immunosuppressants are sometimes used short-term to control severe skin inflammation. However, they carry significant side effects and are generally considered last-resort options. Their use for TSW remains controversial and off-label.
Topical calcineurin inhibitors (TCIs)
Tacrolimus and pimecrolimus are non-steroidal topical immunomodulators used for eczema. Their use in TSW is debated: some clinicians avoid them altogether, while others may cautiously use them on limited areas to control inflammation during withdrawal. Research on their safety in TSW is limited.
Importantly, any use of pharmaceutical agents must be carefully weighed against the risk of prolonging steroid dependence or triggering flares. Many clinicians prefer a watchful waiting approach.
The Role of Tapering
A Gradual Approach to Discontinuing Topical Steroids
One of the most debated topics in 2025 is whether tapering off topical steroids reduces the risk or severity of TSW. Some dermatologists advocate a slow taper — gradually lowering potency and frequency over months — to give the skin and immune system time to adjust.
“Gradually tapering off is essential compared with abrupt discontinuation, particularly if the medication has been used for an extended period “- (Safer & Zito, 2022)
Others argue that tapering may simply prolong steroid exposure and delay recovery, and that “cold turkey” withdrawal is ultimately faster. There is currently no high-quality comparative research proving which method is superior. Most clinicians agree that the decision should be individualised, based on factors such as potency and duration of prior steroid use, patient mental health, and availability of support.
What is clear is that abrupt cessation of very high-potency steroids after long-term use can provoke dramatic rebound inflammation, so medical oversight is essential in either approach.
Research and Future Directions
In 2025, research into TSW remains in its infancy but is expanding. Recent focus areas include:
Defining diagnostic criteria
Proposed by experts like Dr Belinda Sheary, these include essential features (history of long-term TCS use, erythema, burning) and key signs (elephant wrinkles, red sleeve, oozing, edema). Consensus guidelines are still being developed.
Barrier repair technologies
Novel topical formulations (lipid nanoparticles, ceramide-rich creams) are being tested to accelerate barrier recovery without using steroids.
Cold Atmospheric Plasma (CAP)
A newer area of experimental dermatology involves the use of cold atmospheric plasma — ionised gas at near-room temperature — to promote wound healing and reduce microbial load on the skin. Early laboratory studies suggest CAP can stimulate skin cell regeneration, modulate inflammatory pathways, and enhance barrier recovery without thermal damage. While CAP has been trialled in chronic wounds and atopic dermatitis, its application to TSW remains medically unstudied. Nonetheless, its anti-inflammatory and barrier-supporting properties make it a potential avenue for future TSW research.
Immune modulation
Biologics targeting other pathways beyond IL-4/IL-13, such as JAK inhibitors, are being explored cautiously in severe, chronic cases.
These early efforts underscore a growing recognition of TSW within dermatology and the need for rigorous clinical trials.
Moving Forward with Compassion and Caution
TSW can be an isolating and exhausting journey. People navigating it often feel betrayed by the medical system that once reassured them of the safety of topical steroids. This emotional context shapes treatment choices and makes trust-building essential in clinical care.
For now, the mainstay of TSW management remains supportive care, patience, and addressing the underlying eczema if present. Treatments must be personalised, trauma-informed, and approached collaboratively between patient and clinician.
There is still no definitive cure for TSW, and many treatments remain experimental or controversial. Yet as awareness grows in 2025, new approaches are emerging — from biologics and barrier repair therapies to microbiome-based interventions.
While there is no one-size-fits-all path to recovery, ongoing research and open dialogue between the medical community and those with lived experience are slowly illuminating the way forward. With time, care, and compassion, hope continues to grow for safer and more effective treatments for TSW.
From Jason:
📖 After sharing my story of tapering off topical steroids, I’ve received a few heartfelt messages from the community asking me to elaborate on the finer details. This has evolved into a book that I’ve been working on for a long time.
I hope that my story can help anyone who’s on a similar journey.
