Topical steroid withdrawal, often shortened to TSW, has been everywhere on social media over the last few years. The hashtag #TSW has over 1.1 billion views on TikTok alone. One of the problems with social media, and this may sound hypocritical coming from a content creator, is that extreme cases grab our attention. As a result, they evoke strong reactions, are shared widely and can end up dominating our feeds. People who use topical steroids effectively with no issues, which is the overwhelming majority of people with eczema, are unlikely to post about their well-controlled skin because it’s boring to watch. This, coupled with self-diagnosis and online echo-chambers, can give a skewed impression of how common a problem really is, and this makes it hard to judge the true incidence, prevalence and risk of topical steroid withdrawal.
The withdrawal involves a rebound reaction that can occur after stopping topical steroids, usually following prolonged or inappropriate use. It’s generally thought to be rare, affecting only a small proportion of patients presenting to dermatologists though the true prevalence is unknown. Symptoms may include redness, itching, scaling, papules, pustules and a burning sensation. Some people also describe what is often called “elephant skin”, where the skin becomes thickened and folded, which can be caused by fluid retention.
The problem is that other skin conditions, such as severe dermatitis, can look similar, which makes TSW difficult to diagnose. Topical steroids work by reducing inflammation in conditions such as eczema. When they are stopped, the underlying condition can flare again, leading to redness and itching that resembles the symptoms attributed to topical steroid withdrawal.
I’ve had my own experiences with topical steroids. I was diagnosed with eczema at a young age, and I used to scratch my arms so much that they would bleed. Topical steroids were a game changer for me. I’m fortunate that my eczema has improved drastically as I’ve become older, and I’ve only really needed to use topical steroids at most once a year for a few days. When applying topical steroid creams or ointments for eczema, we can improve the absorption and efficacy of the steroids by applying them 20-30 minutes after an emollient. To prevent TSW, we need to ensure topical steroids are used appropriately. The best way of doing this is avoiding prolonged use unless it has been prescribed or advised by your doctor.
The perceived high prevalence and inevitability of TSW that is portrayed on social media is incorrect. Topical steroids are a powerful tool in a doctor’s arsenal, and we use them for so many conditions. For example, otitis externa (infection of the outer ear canal), phimosis (tight foreskin) and lichen sclerosus (an inflammatory skin condition that can cause scarring and structural changes to the genitals).
The British Association of Dermatologists, in a joint statement, acknowledge topical steroid withdrawal and the need for further research in this area. However, it also emphasises that topical steroids have been used safely and effectively for over 70 years, and that fear of TSW should not put people off a treatment that can be very helpful. What matters most is using steroids appropriately and working with patients who develop concerning symptoms to explore alternative treatment options when needed.
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References:
1. DermNet NZ. Topical corticosteroid withdrawal [Internet]. Auckland: DermNet New Zealand Trust; [cited 2025 Dec 16]. Available from: https://dermnetnz.org/topics/topical-corticosteroid-withdrawal
2. National Eczema Society, British Dermatological Nursing Group, British Association of Dermatologists. Topical Steroid Withdrawal: Joint Statement [Internet]. 2024 Feb [cited 2025 Dec 16]. Available from: https://cdn.bad.org.uk/uploads/2024/02/22095550/Topical-Steroid-Withdrawal-Joint-Statement.pdf