Topical steroid withdrawal

Before discontinuation, steroid dermatitis is characterised by spreading dermatitis and worsening skin inflammation, which requires a stronger topical steroid to get the same result as the first prescription. This cycle is known as steroid addiction syndrome.^[13] When topical steroid medication is stopped, the skin experiences redness, burning, itchiness, scabs, hot skin, swelling, stinging, hives, or oozing. This is known as topical steroid withdrawal. After the withdrawal period is over, the atopic dermatitis can cease or is less severe than it was before.^[9] Topical steroid withdrawal has also been reported in the male scrotum area.^[14] Other symptoms include nerve pain, insomnia, excessive sweating, anxiety, depression, fatigue, eye problems, and frequent infections.^{[citation needed]}

To experience this withdrawal, it generally requires the misuse or application of a topical steroid daily for 2 to 4 months, depending on the potency of the topical corticosteroid. In some cases, this has been reported after as little as 2 weeks of use.^[16][1]

Historically, it was believed that cortisol was only produced by the adrenal glands, but research has shown that keratinocytes in human skin also produce cortisol.^[17] Prolonged topical steroid (TS) application changes the glucocorticoid receptor (GR) expression pattern on the surface of lymphocytes; a patient experiencing resistance to a TS has a low ratio of GR-α to GR-β. In addition, the erythema characteristic of ‘red skin syndrome’ is due to a release of stored endothelial nitric oxide (NO) and subsequent vasodilation of dermal vessels.^[1]

A 2025 pilot study by Shobnam et al. (n=16) reported that topical steroid withdrawal is associated with overexpression of mitochondrial complex I, leading to elevated NAD+ and the conversion of tryptophan into kynurenine metabolites; the authors also reported symptom improvement in an open-label series treated with mitochondrial complex I inhibitors.^[18] The findings have been the subject of academic correspondence in the United Kingdom. Brown and Burleigh argued in the Journal of Investigative Dermatology that the small sample size and underpowered analyses meant the proposed molecular and cellular mechanisms remained unexplained and warranted further research.^[19] In reply, Shobnam et al. agreed that larger studies are needed and that the diagnostic criteria lacked specificity, while maintaining that the work nonetheless provided initial mechanistic insights.^[20] A separate letter by Tan, Dawe and Affleck in Clinical and Experimental Dermatology raised concerns that recruitment through topical steroid withdrawal advocacy organisations introduced collider bias.^[21] In a 2026 narrative review in Frontiers in Medicine, Myles and Ratley defended the study design while acknowledging that biomarkers obtainable in standard clinical laboratories have not yet been identified and that the proposed mechanisms require validation in larger cohorts.^[8]

Diagnosis is based on a rash occurring within weeks of stopping long-term topical steroids.^[2] Specific signs include "headlight sign" (redness of the lower part of the face but not the nose or the area around the mouth), "red sleeve" (a rebound eruption stopping abruptly at the lower arms and hands), and "elephant wrinkles" (reduced skin elasticity).^[3]

Differentiating this condition from the skin condition that the steroids were originally used to treat can be difficult.^[2] Red, burning skin may be misdiagnosed.^[9]

This condition can be avoided by not using steroid creams for periods of time longer than 2 weeks.^[2][3]

Treatment involves ceasing all use of topical steroids, either gradually or suddenly.^[2] Antihistamines may help for itchiness.^[3] Immunosuppressants and light therapy may also help some people.^[3] Psychological support is often recommended.^[2][3][16] At this time, treatment options that have been documented in literature include tacrolimus, pimecrolimus, and dupilumab (Dupixent). Some physicians have also seen positive outcomes with oral doxycycline or topical clindamycin.^[22]

The prevalence of the condition is unknown.^[23] Many cases ranging from mild to severe have been reported in both adults and children. One survey of atopic dermatitis patients treated with topical steroids in Japan estimated that approximately 12% of adult patients may appear to be uncontrolled cases, although they are in fact addicted to a topical steroid.^{[9][clarification needed]}

A systematic review (meta-analysis) in accordance with evidence-based medicine frameworks and current research standards for clinical decision-making was performed in 2016 and was republished with updates in 2020.^[24]