Topical steroids are a common pharmaceutical solution of treating skin disorders such as eczema and psoriasis. Topical corticosteroids are indicated only for short term use. Several side effects are observed when these medicines are used for extended periods, whether topically or systemically. Contrary to this, there are new stories emerging across social media of people who have used topical steroids for less than 2 weeks, and going into withdrawal symptoms upon the cessation of the steroids.

One of the probable side effects of topical corticosteroid overuse is atrophy. In such cases, the skin loses perfusion and becomes parched and wrinkly. This adverse effect is only witnessed in about 5% of people who use the steroid to treat psoriasis. Steroid-induced skin atrophy is thinning of the skin as a result of prolonged exposure to topical steroids steroids.

It may be interesting to note that even oral corticosteroids can produce the same side effects. The atrophy is localised to the application site with topical steroids, unlike with oral corticosteroids.

Physiology and Pathogenesis of Atrophy in Corticosteroid Use

Topical corticosteroids prevent inflammation by inhibiting an enzyme called Phospholipase A2. Phospholipase A2 is responsible for releasing arachidonic acid, which causes inflammation. Topical corticosteroids achieve this inhibition cycle through lipocortin, which directly inhibits Phospholipase A2.

However, Phospholipase A2 is not the only protein that topical steroids inhibits. Collagen, an essential structural protein, declines when corticosteroids are overused. This decline heralds the process of atrophy formation. This spreading atrophy causes a stinging or burning sensation, sending off a signal that results in vasoconstriction.

When the steroid is withdrawn, the constricted blood vessels become dilated once more. The longer the steroid was employed, the more dilation will occur when it is finally discontinued. This causes a ‘’trampoline-effect’’, where the resulting vasodilation outweighs the initial vasoconstriction it wishes to counterbalance. 

Signs and Symptoms on Atrophy and Skin Thinning

Atrophied skin is dry, wrinkled and is very easily bruised. Atrophy often comes with telangiectasia, purpura and striae.

Occlusive dressings such as too-tight bandages and plasters are known to worsen the signs of atrophy. Steroids combined with halogens are more likely to cause adverse effects.

Prevention of Steroid Induced Atrophy and Skin Thinning

The most obvious prevention of steroid induced atrophy is to not use topical steroids at all, however for many, that may not be possible or too late.

Common Recommendation by doctors:
When topical corticosteroids are used for short periods, doctor's suggest there is a smaller risk of atrophy. Since topical steroids comes in various potency grades, it is common for doctors recommend to stick to the recommended class for a particular body part. For example, applying hydrocortisone cream once a day to the affected site is considered a Level 1 treatment. The higher strength steroid creams are often reserved for the trunk, while sensitive areas like the face and genitals are commonly treated with only low potency corticosteroids. 

Many people with topical steroid withdrawal (also known as Red Skin Syndrome) do not agree with the above recommendation, however have included it there for reference.


Treatment of Topical Steroid Withdrawal and Skin Atrophy

Due to topical steroid withdrawal being an adverse effect to a pharmaceutical drug, it is only just being recognised a medical phenomena and not yet an illness. Currently there is no cure or standardized medical treatment. The time it to takes to heal from topical steroid withdrawal is still unknown and is unique from person to person. 


Our Mission at TSW Assist

Through community recommendations from people who suffer from topical steroid withdrawal, there are routines, treatments, and therapies that can help manage the topical steroid withdrawal process. Our purpose is to empower the TSW community with data and solutions to improve their skin health, reduce inflammation, and reduce suffering during the withdrawal period.

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