Steroid Phobia: Is There a Basis? A Review of Topical Steroid Safety, Addiction and Withdrawal

Abstract

There is a growing concern amongst patients about topical corticosteroid (TCS) side effects, with increasing discussion of topical steroid addiction (TSA) and topical steroid withdrawal (TSW) particularly on social media platforms. However, the acceptance of TSA/TSW as a distinct condition remains controversial within the dermatological community. We conducted a literature search using PubMed, MEDLINE, Cochrane Library, Google Scholar, Embase and Web of Science to identify original articles addressing TSA/TSW. We described the definition and reported clinical features of TSA/TSW including its classification into erythemato-edematous and papulopustular subtype. To assess the validity of TSA/TSW, we summarised and objectively appraised the postulated mechanisms for this condition, including tachyphylaxis, dysregulation of glucocorticoid receptors, rebound vasodilation and impaired skin barrier leading to a cytokine cascade. Understanding the evidence including its limitations and uncertainties highlights areas for future research and helps medical practitioners better counsel and provide care to patients who may be experiencing or who have concerns about TSA/TSW.

Qualitative analysis of topical corticosteroid concerns, topical steroid addiction and withdrawal in dermatological patients

“…With the emerging availability of other topical non-steroidal alternatives such as calcineurin inhibitors,39 phosphodiesterase inhibitors40 and Januse kinase (JAK) inhibitors,41 physicians will be better equipped to provide a wider range of alternatives for patients who wish to avoid TCS. Systemic medications which have been accepted by patients with TSA/TSW also include oral antibiotics and dupilumab 10. Although these may be more costly or less effective, they could be offered early in the therapeutic relationship as alternatives to TCS with appropriate counselling and management of expectations.…”

“…There is significant controversy regarding the concept of steroid addiction and withdrawal (TSA/TSW) as a distinct clinical syndrome and current literature is conflicting 10. Physicians’ sensitivity and open-mindedness in discussing the topic with the patients is necessary, regardless of the plausibility or source.…”

“…TCS concerns may also include a fear about topical steroid addiction and withdrawal (TSA/TSW). Although TSA/TSW is a controversial entity within the dermatological community,10 it has a growing online community on social media platforms and websites such as the ‘International Topical Steroid Awareness Network (ITSAN)’ 11…”

Management of Atopic Dermatitis: The Role of Tacrolimus

“…ADRs such as atrophy, striae, rosacea, perioral dermatitis, acne, and purpura are repeatedly reported. Hypertrichosis, pigmentation remodeling, retard traumatic lesion to reinvigorate process, and exasperation of dermatological infections are also low in frequency [59,60,[63][64][65]. Therefore, it has been advised that even topical glucocorticoid administration should be carefully monitored to minimize ADRs [61,62].…”

Steroid phobia on social media platforms

“…Steroid phobia negatively impacts treatment and can increase rates of non‐adherence when it comes to treating AD with TCS 5 . Growing concerns regarding the side effects of TCS have been accompanied by increasing discussions of topical steroid addiction (TSA) and topical steroid withdrawal (TSW) on social media platforms 6 . However, TSA and TSW are rarely noted in the medical literature, particularly in children 7 .…”