Eczema and the Topical Steroid Withdrawal Controversy

MANCHESTER, England – Is topical steroid withdrawal (TSW) a clinical entity in its own right or a flare-up of existing eczema? That shouldn’t matter when it comes to treating the patient in front of you, experts said at the British Association of Dermatologists (BAD) 2026 Annual Meeting. “No patient should have to go through TSW,” said Rowena Mills, a paediatrician working in the West Midlands, England. Mills explained to a packed room how she had endured the life-changing effects of TSW firsthand as she related her decade-long experience of the condition before finally getting the treatment and relief that she needed. Calling it her “greatest life challenge,” Mills said that “it was so uncomfortable. Your skin is your biggest organ; if it's inflamed, then you're going to be in so much pain.” Characterized by red, itchy, and burning skin that may peel, crack, and blister, TSW is a controversial condition that has been noted to occur after treatment with mid-to-high-potency topical steroids is stopped. However, as Mills could testify, it can also occur when milder steroids are used. Concern Over Topical Steroids Andy Proctor, chief executive officer of Eczema UK, observed that “the concern about using topical steroids to manage flare-ups is growing.” Proctor said that many patients with eczema who are managed by general practitioners are only offered topical steroids and there is often no plan B. That situation may, however, change in the future if non-steroidal topical treatments such as ruxolitinib and delgocitinib make their way into the primary care setting. “From the perspective of the patient community, people are worried about it, and they want their clinicians, their healthcare professionals, to listen,” Proctor told Medscape News UK. People are turning to social media because of a lack of direction from clinicians on how to manage TSW, Proctor said. The challenge is that that there are few, if any, data on the condition and thus no clear acceptance or guidance for healthcare professionals. “Even if healthcare professionals are unsure, don't know, or don't agree, listen and just be honest, and say that we don't know enough to be able to provide clear guidance on this at the moment,” advised Proctor. Respect the wishes of people who feel that steroids are not for them and support them in the best way that you can, Proctor suggested. This may mean just reiterating the standard advice given to people with eczema on using daily emollients and other means to help manage their skin symptoms or perhaps putting in a referral sooner into secondary care. Defining TSW Although there is currently no agreed definition or diagnostic criteria for TSW, the UK’s Medicines and Healthcare products Regulatory Agency (MHRA) recognized TSW in 2021, said Professor Celia Moss, MD, a retired paediatric dermatologist. Moss, who remains an honorary consultant dermatologist at Birmingham Women’s and Children’s NHS Foundation Trust and is an honorary professor of paediatric dermatology at the University of Birmingham, said that the MHRA had stipulated that a warning paragraph must be included in the patient information leaflets of all topical steroids used for eczema. The warning paragraph states that withdrawal of topical steroids after prolonged use can result in a skin reaction that “might appear to be different from the previous condition.” The reaction can occur days to weeks after treatment is stopped and can spread beyond the initial treatment area. Following on from this, Eczema UK (then called the National Eczema Society), the British Derma Group, and BAD issued a joint statement that described the various reactions reported by patients. “The bottom line was that that we agreed that it's a heterogeneous condition,” Moss said. The urgent need to undertake high-quality research to understand the condition better was recognized. Last year, BAD established a working group to look further into the condition and, separately, Moss and Mills have recently proposed terminology that could be used to pull together the clinical features seen by clinicians and the terms used by patients. Some people using topical steroids call TSW "steroid addiction" or "red skin syndrome," Moss explained. Clinicians, however, may view these cases differently. They may classify the symptoms as eczema that is generally well controlled with appropriate intermittent topical steroid use but naturally goes through periods of relapse and remission. Alternatively, they may see it as eczema that has become uncontrolled and requires escalating doses or more potent steroids. Moss and Mills proposed terminology that places these cases on a spectrum, ranging from controlled eczema that is not TSW, to steroid-dependent eczema, early TSW, classic TSW, relapsing TSW, and, finally, recovered TSW. Steroids Remain Effective Eczema Treatment Steroids are an effective treatment for eczema, Moss, Mills, and Proctor maintained. However, they need to be used as directed by a clinician and according to the prescribing information, meaning for short periods and intermittently. Mills was never told that TSW could occur if she stopped taking her topical steroids. She said she had felt guilt, shame, embarrassment, and had even doubted herself, feeling that, as a clinician, she should have been able to do something to prevent the condition from happening to her. “Going through this has made me far more compassionate as a clinician. I know how hard it is to live with this. I also learned to adapt my life around it,” she said. Mills cycled through multiple treatments while trying to live with TSW, including oral steroids and immunosuppressants, until finally she recovered after being prescribed the biologic dupilumab. Mills suggested that while topical steroids can be used safely, and she still prescribes them to her patients, TSW should be a consideration if treatment stops. Additionally, if a patient needs moderate- to severe-potency steroids, she said it’s important to consider whether a steroid-sparing agent should be prescribed if they were eventually going to stop taking these drugs. “Ultimately topical steroid withdrawal is a drug side effect which could be avoided,” she said. Audience Reaction Yvonne Abimbola, a general practitioner based in Sussex with a specialist interest in dermatology, commented that if someone is not doing well on topical steroids, then perhaps the diagnosis needs to be looked at. “I find that there's quite a lot of misdiagnoses at the beginning of someone's eczema,” she said. People could have seborrheic dermatitis, for example, and could be put on the wrong treatment pathway as a result, with escalation in therapy rather than re-examining whether the right condition had been identified. “So I think the work needs to be done mostly in education of what the symptoms are [of TSW], and how they look different,” she said. All persons quoted in this article reported no relevant financial interests. Sara Freeman, BSc, MSc, is a freelance medical journalist based in London, UK. She has been reporting for specialist healthcare news organisations for more than 20 years.