The fear of topical steroids may derive from a combination of myths, misperceptions, and experiences with medical professionals who lacked the knowledge to explain or prescribe topical steroids correctly.
~ Dr. Kelly Cordoro
Topical steroids have long been used as a treatment for the condition of atopic eczema, also known as atopic dermatitis. While the treatment has proven successful for millions of patients over the years, it is still a hotly debated topic – primarily due to the potential side-effects of using steroids and the collection of stories where steroids were used inappropriately.
What are the risks? The goal here is to better assess the dangers of topical steroids when used to treat eczema.
According to the National Eczema Association, topical steroids have been used to treat eczema for over 50 years. Knowing this and understanding that eczema is said to currently affect 35 million people in America alone, it seems obvious that treatments have varied over the years – and so have results.
As with any popular treatment, there are extreme examples that can be found. With eczema and any other skin condition where steroids are used, there are cases where extreme amounts of steroid were supplied and this led to undesirable results. You may have heard of such conditions as “red skin syndrome” (commonly referred to as RSS) and topical steroid addiction.
Red skin syndrome (also known as steroid rosacea) is a term coined by Dr Marvin Rapaport MD, an American dermatologist who believes that steroids are responsible for the red skin (rebound) that results when eczema sufferers discontinue the use of steroids. If this logic sounds a bit non sequitur, there may well be good reason for it.
Eczema, by it’s very nature, has the same symptoms as red skin syndrome; red, inflamed, hot or oozing skin – as it’s often described. There is no official diagnosis for the condition since it’s not recognized by most doctors and health care officials.
Red Skin Syndrome (topical steroid addiction) appears to be a real entity that we still need to learn more about. However […] it seems that it can be very difficult to distinguish from eczema itself – this is part of what makes it so challenging.
~ Chicago Integrative Eczema Center
This is not to say that red skin syndrome does not exist. In fact, it does. Tachyphylaxis is a medical term describing an acute decrease in the response to a drug after its administration. As the response lessens, a typical reaction is to increase dosage to keep achieving the desired effect. Rather a person is taking steroids to treat skin, aspirin to treat a headache or ingesting greater amounts of caffeine for an increase in energy, a tolerance is built up.
Red skin syndrome may well be a result of using too many steroids but does this mean that you should immediately stop the use of all steroids or are there other factors being overlooked?
The unfortunate result of many individuals and websites reading about red skin syndrome on the internet has led to the self-diagnosis of topical steroid withdrawal – and the immediate decision to discontinue steroid use for treatment. This is an irresponsible approach to a rather serious condition.
Topical steroids, when prescribed correctly, are very rarely the problem and will almost always yield positive results for individuals suffering with eczema.
Throughout the years, steroids have been inappropriately prescribed for many patients – starting with absurdly high dosages and increased when the positive effects were no longer being seen. Unfortunately, this has sometimes led to the poor approach of being prescribed an even greater amount of steroids and many have seen their conditions worsen.
This irresponsible approach to medicine has cast a negative light on a very effective eczema treatment. However, it is important to be aware of these cases so that we may further educate ourselves on the pros and cons of using steroids.
All Steroids Are Not Created Equal
The internet is full of stories about steroid addiction. While many of these cases are certain to be a result of incorrect self-diagnosis, there are many accounts that seem authentic – individuals who have used highly potent steroids for years and increased dosage all the while to overcome the effects of tachyphylaxis.
What’s missing from nearly every conversation is a focus on the type and potency of steroids involved. While many seem to understand that every steroid has a different potency, few seem to factor this in to the equation of steroid abuse. To make a blanket statement such as “all steroids are bad” or “steroids will eventually cause thin skin” is to assert that all steroids behave and react in the same way – and cause the same side effects – regardless of the potency, duration and time frame. We know that’s not true.
Let us first examine the difference in oral steroids vs topical steroids and reveal some information that some find surprising.
While nearly everyone seems to understand that topical steroids can be absorbed by the skin and potential harm can result, very few articles are found on the likelihood of this occurrence.
Dr. Kohhei (Tadahiro) Makise, M.D has treated thousands of eczema patients over the years and is considered to be one of the most cutting-edge physicians in Japan. He notes an important distinction between oral and topical steroids – in that oral steroids are far more dangerous.
The adverse drug reactions to orally taken steroids include a variety of symptoms such as hypertension, moon face, gastric ulcer, diabetes mellitus, psychosis, cataracts, decreased immunity, and osteoporosis. If steroidal ointment is applied to the skin, a patient shouldn’t worry about these side effects. In order to have the same adverse drug reaction induced by oral steroids, patients must use an exorbitant amount of steroidal ointment on the skin. Everyday application of two 10-gram-tubes of the strongest steroidal ointment such as Dermovate or Diflar all over the body for 1 month will only bring about at most the same amount of absorption of the steroid hormone into the body as when 1 tablet of Predonine (prednisolone) is orally administered. This makes it virtually impossible for the application of topical steroidal ointments to bring about the same side effects induced by oral steroids.
This information is further substantiated by a medical study that was published in Pediatric Dermatology in 2011.
This study observed 70 children who had been using a topical steroid for 10.6 months and an additional 22 children who had never before used steroids on their skin, to act as a control group. The children were given topical steroids for an additional three months and their skin was checked with a dermascope. Two researchers examined four pathches on each child’s skin to determine if any amount of thin skinning had occurred. In both groups of children, there were no signs of skin atrophy.
The results of the study?
We conclude that routine, appropriate, long-term use of TCS (Topical Corticosteroids) in children with dermatitis does not cause skin atrophy. These data do not support the widely held belief that routine use of TCS will “thin the skin”. Parents, pharmacists, and health practitioners should be confident about the safety of using this treatment.
The majority of dermatologists and health care specialists share the belief that topical steroids can be effectively used to treat steroids. Indeed, millions of people have been helped by this treatment without side effects occurring.
Dr. Kelly Cordoro is Board Certified in Dermatology and Pediatric Dermatology and is an Assistant Professor of Dermatology and Pediatrics and the Assistant Chief of the Division of Pediatric Dermatology at the University of California, San Francisco – with a primary focus on atopic dermatitis.
Dr. Cordoro advises against letting a child suffer by withdrawing the use of topical steroids to treat eczema and notes the many problems that can be encountered when not treating
This is the message I want you to understand: topical steroids are one of the most effective medications used to treat skin disease, and they have been used effectively for over three decades. There can be risks if these medicines are used incorrectly; however, their safety can be assured when a dermatologist or physician who is experienced and knowledgeable with their use does the prescribing. Ironically, not using a topical steroid when prescribed appropriately can create more problems than using it, as skin disease and itch can lead to attention deficits in school, poor sleep, and disruption of the entire family dynamic.
As a whole, the medical community is desperately trying make the public aware that topical steroids, when used correctly, are a gold standard of treatment for the relief and healing of eczema. Steroid phobia is at an all time high as a result of internet rumors and ignorance of an issue that doctors are yearning to better educate the public on.
Peter Lio, MD, assistant professor of clinical dermatology and pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, and director of the Chicago Integrative Eczema Center, is among the physicians working with the National Eczema Association to address steroid phobia with medical evidence and advice.
“We don’t want people to think we’re not hearing them; we hear them. Steroid phobia is real and it’s important to treat these medicines with respect because they are powerful,” Lio says. “However, what’s wonderful is, when used correctly, topical steroids can give tremendous relief and help break the scratch-itch cycle without causing significant problems.”
Any treatment ultimately comes down to risk vs benefit and when it comes to treating eczema, topical steroids provide the lowest risk and the greatest benefit.
What is Appropriate Use of Steroids?
It’s actually a pretty simple question to answer. Are steroids being prescribed to you in such a manner as to reduce usage as time goes on or is there a steady increase in dosage with no end in sight?
If it’s the latter, you’re likely on your way to steroid addiction and the side effects of steroids may become noticeable and more severe – but even in such a case, we recommend weaning off of steroids in a manner such as Dr. Aron prescribes. The biggest mistake a person can make at this point is jumping in to TSW and worsening both your symptoms and your suffering.
The unfortunate truth is that there are still many doctors prescribing steroids irresponsibly. If you feel that you are at risk with your treatment, ask your doctor if there’s a plan to reduce steroid usage? For effective treatment of eczema, this has to happen.
Dr. Aron uses only topical steroids for the treatment of eczema and he prescribes the steroids in such a manner that usage is tapered down until no longer needed. His mixture consists of a moisturizer, an antibiotic to immediately fight the bacterial infection and a diluted steroid to combat the inflammation. His mixture doesn’t sting like most creams and there’s nothing more effective.
It is Dr. Aron’s hope – and ours – that no child in need of help has to suffer from the pain of eczema.
The risk of topical steroids are greatly hyped while the pain and suffering one must endure in topical steroid withdrawal is vastly understated.